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Power to Prevent - National Diabetes Education Program - National ...

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Post-Session 3 Questionnaire<br />

(Fill out this questionnaire at the end of session 3)<br />

Name or other identifer (such as initials with day and month of birth): ______________________<br />

1.<br />

2.<br />

3.<br />

Don’t know or refused<br />

Three healthful meals I can prepare for myself (and my family) are:<br />

(Check “Don’t know or refused” if you do not know or do not want <strong>to</strong> answer.)<br />

Nutrition-Related Lessons<br />

Please circle one number <strong>to</strong> indicate how strongly you agree or disagree with the following<br />

statements. (Check “Don’t Know or Refused” if you do not know or do not want <strong>to</strong> answer.)<br />

1. I know how <strong>to</strong> create healthful<br />

lunches.<br />

2. I eat less healthily when I feel<br />

stressed.<br />

Strongly<br />

agree<br />

Agree<br />

Neither<br />

agree nor<br />

disagree<br />

Disagree<br />

Strongly<br />

disagree<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

3. I am confdent I can eat more fruits<br />

and vegetables every day (or that I 5 4 3 2 1<br />

am at my goal for this).<br />

4. I understand what a single serving<br />

for my favorite foods is.<br />

5. I understand how <strong>to</strong> read food<br />

labels <strong>to</strong> choose foods lower in fat.<br />

6. I can think of healthy food choices<br />

I like <strong>to</strong> eat.<br />

7. I know how <strong>to</strong> identify drinks with<br />

added sugar.<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

8. I can fnd healthful food items<br />

<strong>to</strong> eat at my favorite fast food<br />

restaurants.<br />

5 4 3 2 1<br />

9. I know ways <strong>to</strong> control overeating<br />

or eating high-fat foods when I eat<br />

out.<br />

5 4 3 2 1<br />

10. I can think of small steps I can take<br />

<strong>to</strong> eat more healthily.<br />

11. I am confdent I can take small<br />

5 4 3 2 1<br />

steps in healthy eating that will <strong>to</strong><br />

lead <strong>to</strong> a big reward of improved<br />

health.<br />

5 4 3 2 1<br />

Don’t<br />

know or<br />

refused<br />

NDEP <strong>Power</strong> <strong>to</strong> <strong>Prevent</strong> Appendices 46

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