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

Post-Session 6 Questionnaire
(Fill out this questionnaire at the end 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.
Strongly
agree
Agree
Neither
agree nor
disagree
Disagree
Strongly
disagree
5 4 3 2 1
5 4 3 2 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
Physical activity helps people who have diabetes
and people who want to prevent diabetes by:
1.
2.
3.
Don’t know or refused
Three questions people with diabetes should ask their doctor at each visit are:
Three signs/symptoms of diabetes are:
1. ________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________
Don’t know or refused ___________________________________________________________________________________
1.
2.
3.
Don’t know or refused
By controlling or preventing diabetes, I can protect
myself from the following health problems:
2.
2.
3.
Don’t know or refused
NDEP Power to Prevent Appendices 55