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

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Pre-Session 4 Questionnaire<br />

(Fill out this questionnaire at the beginning of session 4)<br />

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

Physical Activity-Related Lessons<br />

1.<br />

2.<br />

3.<br />

Don’t know or refused<br />

Three health benefts of physical activity are:<br />

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

Physical Activity-Related Lessons<br />

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

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

Strongly<br />

agree<br />

Agree<br />

Neither<br />

agree nor<br />

disagree<br />

Disagree<br />

Strongly<br />

disagree<br />

1. I understand the connection<br />

between physical activity and 5 4 3 2 1<br />

diabetes prevention.<br />

2. I understand why properly ftting<br />

shoes are important for a person 5 4 3 2 1<br />

with diabetes.<br />

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

<strong>to</strong> increase my physical activity.<br />

4. I am confdent I can be more<br />

physically active.<br />

5. I can name physical activities I can<br />

do <strong>to</strong> reduce stress.<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

Don’t<br />

know or<br />

refused<br />

Please put your name (or your initials with day and month of birth) on this questionnaire<br />

and give it <strong>to</strong> your program leader.<br />

NDEP <strong>Power</strong> <strong>to</strong> <strong>Prevent</strong> Appendices 48

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