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

Pre-Session 6 Questionnaire
(Do this pre-session questionnaire at the beginning of session 6)
Name or other identifer (such as initials with day and month of birth): ______________________
Diabetes-Related Lessons
Please circle one number to indicate how strongly you agree or disagree with the following
statements. (Check “Don’t know or refused” if you do not know or do not want to answer.)
1. I know what the “ABCs of
diabetes” stands for.
2. I understand the connection
between the ABCs and
preventing diabetes
complications.
1.
2.
3.
Physical activity helps people who have diabetes
and people who want to prevent diabetes by:
Don’t know or refused
Strongly
agree
Three questions people with diabetes should ask their doctor at each visit are:
5
Agree
4
Neither
agree nor
disagree
1. ________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________
Don’t know or refused ___________________________________________________________________________________
3
Disagree
2
Strongly
disagree
5 4 3 2 1
1
Don’t know
or refused
What do you know about diabetes right now?
Fill in the blanks. (Check “Don’t know or refused” if you do not know or do not want to answer.)
1.
2.
3.
Three risk factors for type 2 diabetes are:
Don’t know or refused
1.
2.
3.
Three signs/symptoms of diabetes are:
Don’t know or refused
By controlling or preventing diabetes, I can protect
myself from the following health problems:
1.
2.
3.
Don’t know or refused
NDEP Power to Prevent Appendices 53