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

Post-Program Questionnaire
(Fill out this post-program questionnaire at the beginning of session 12)
Name or other identifer (such as initials with day and month of birth): ______________________
Thanks for participating in our program! This questionnaire was given to you at the beginning of
the program. Now we would like you to fll it out again. Please make sure that your group leader has
your home address so that a copy of this questionnaire can be sent to you. Then you can compare
your answers from the frst session with these answers to see how far you have come.
Goals and Expectations
My goals in this program were to: (Please check all that apply, or write in your own.)
Lose weight
Feel better about myself
Become more physically active
Learn to eat and/or cook more healthily
Learn more about how to control diabetes in general
Take control over my diabetes
Prevent diabetes in myself and/or my family
Other:_________________________________________________________________________
In this program I did the following: (Please check all that apply, or write in your own.)
Learned more about diabetes control
Learned more about diabetes prevention
Gained support from other members of the group
Became able to teach my family about diabetes prevention
Became able to make changes in my eating
Became able to make changes in my physical activity
Other:_________________________________________________________________________
NDEP Power to Prevent Appendices 59