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

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Please answer the following.<br />

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

1. How often do you skip a meal and then<br />

snack or overeat?<br />

2. How often do you eat foods high in fat,<br />

like fried foods or lots of butter, cheese, or<br />

lard?<br />

3. How often do you eat more than you think<br />

you should?<br />

Daily<br />

Several<br />

times a<br />

week<br />

A few<br />

times a<br />

month<br />

Once in<br />

a while<br />

Rarely<br />

or never<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

5 4 3 2 1<br />

How confdent are you that you can make changes now?<br />

Please circle one number <strong>to</strong> indicate how confdent you are that you can make the following<br />

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

Physical Activity Sure I<br />

can<br />

Think I<br />

can<br />

Not sure I<br />

can<br />

Don’t<br />

think I can<br />

1. Get physical activity more often 4 3 2 1<br />

2. Be physically active for longer time 4 3 2 1<br />

Eating Sure I<br />

can<br />

Think I<br />

can<br />

Not sure I<br />

can<br />

Don’t<br />

think I can<br />

3. Eat more healthful food 4 3 2 1<br />

4. Overeat less often 4 3 2 1<br />

Medication Taking<br />

(if Applicable)<br />

Sure I<br />

can<br />

Think I<br />

can<br />

Not sure I<br />

can<br />

5. Miss fewer medications 4 3 2<br />

6. Take medications on time 4 3 2<br />

General Health Sure I<br />

can<br />

Think I<br />

can<br />

Not sure I<br />

can<br />

Don’t<br />

think I can<br />

Don’t<br />

think I can<br />

7. Lose weight 4 3 2 1<br />

8. Get support from family/friends 4 3 2 1<br />

9. Get blood pressure under control 4 3 2 1<br />

10. Handle stress better 4 3 2 1<br />

Don’t know<br />

or refused<br />

Don’t know<br />

or refused<br />

Don’t know<br />

or refused<br />

Don’t know<br />

or refused<br />

Don’t know<br />

or 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 6

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