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Diabetes Management Questionnaire
Thank you for taking the time to complete this questionnaire. Your answers help us to provide a useful diabetes intervention program, which is intended to help our clients - you to be more confident in managing your diabetes and self care of your diabetes. Your participation in this survey is voluntary and all information about is confidential. Please continue to complete the following survey if you wish.
*
Indicates required field
Please state your age.
*
26-35
36-50
Over 50
51-70
Prefer not to say
Please state your gender
*
Male
Female
You have been diagnosed with diabetes type 2
*
Yes
No
You are overwieight and would like to learn the principles of healthy eating
*
Yes
No
How important is your health?
*
Very Important
Important
Neutral
Somewhat Important
Not at all Important
Your weight
*
Height
*
Is your waist bigger than you would like?
*
Goal weight
*
How often do you exercise?
*
4-5 days/week of 60 minutes intense physical activity e.g. running, boxing, footie
Average - 30 minutes/day of moderate physical activity e.g. walking, jogging, cycling
Somewhat - 2-3 times/week of 30 minutes moderate physical activity e.g. walking
Not active - no physical activity which raises the heart rate above rest level
If Other please specify:
*
How healthy and balanced is your daily diet?
*
Healthy and balanced
Somewhat healthy and balanced
Neutral in health and balance
Somewhat unhealthy and unbalanced
Quite unhealthy and unbalanced
Please describe what you consider to be healthy and balanced
*
How often, on a weekly basis, do you drink alcohol?
*
more than 2 standard drinks a day
2 standard drinks a day
5 days a week
occaisionally
rarely
never
If you drink alcohol, please indicate what types and how many drinks on average per week?
Pre Mix
*
None
1-3 drinks
4-7 drinks
8-12 drinks
Beer
*
None
1-3 drinks
4-7 drinks
8-12 drinks
Cider
*
None
1-3 drinks
4-7 drinks
8-12 drinks
Wine
*
None
1-3 drinks
4-7 drinks
8-12 drinks
Spirit
*
None
1-3 drinks
4-7 drinks
8-12 drinks
On a weekly basis, how often do you feel you have too much stress or pressure from work, family, social or personal life which affects the quality of your life?
*
Always
Most days of the week
Half the week
Couple/week
Never
What do you feel are your main barriers to managing your diabetes?
*
Not enough time or skills to prepare and eat healthy meals
Poor understanding of diabetes and how to control it
Lack of support and motivation from family and friends
Stress
other
*
Have you previously participated in any weight or diabetes management programs?
*
Yes
No
If yes, where?
*
How effective do you feel was the previous program?
*
Not effective at all
Somewhat effective
Neutral
Effective
Very effective
If you found the program to be effective, what made it effective?
*
Were you able to continue with any of the following since the program finished?
*
Weight loss
Improved eating habits
Feeling more energetic and fitter
Better blood glucose control
Improved self esteem and confidence
If you continued with any of the above, what made it easier for you to do so?
*
If you did not continue with any of the above, what made it harder for you to continue?
*
Where you able to maintain the success after you completed the program?
*
Yes
No
From the following activities, please indicate which one you would like to be included in the program for diabetes management we are developing?
*
Ongoing lessons/demonstrations on safe exercise
Cooking classes that are simple and healthy
Education only seminars
Restaurant/cafe outing to practice better menu selection
Supermarket tours to learn the better products to purchase, and how to know
What topics would you like to learn about to help you improve your blood glucose control?
*
Making healthier food choices when eating at home and also when eating out
How to control and maintain blood glucose control easily
Safe and effective exercise and training that you can do in your own home
Other health issues related to diabetes 2 and how to prevent their development
Long term self care around your overall health
From the following options, how would you know if this program was a success for you?
*
Lost weight and kept it off for at least 6 months
Improved your fitness level and ability to move around easier
Your food choices are generally more healthier than they previously were
You have more understanding of diabetes and how to manage it.
Your self esteem and confidence in general improved
Other please specify
*
Please describe your overall goal/s you have if you attended a diabetes management program. It can be as simple or as detailed as you choose to share.
*
How many sessions you reasonable to commit to such a program to help you achieve your desired outcomes?
*
8 weeks, 1 morning for 2 hours per week
4 weeks, 2 mornings, for 2 hours per week
4 Saturday mornings for 3 hours
4 Sunday afternoons for 3 hours
other that you would like
To help us provide you with the best possible materials during the program, how much would you be willing to contribute towards the program?
*
$20 per session
$10 per session
$15 per session
Which of the following would you like to attend the program?
*
Days
Night
Weekend
Which is the better time for you to attend?
*
Mornings 10-12
Afternoon 1-3
Evening 6-8
I request to receive the information regarding the diabetes management program
*
Yes
No, thank you. Not at this time
In 6 months time
What is your preferred contact method to keep you upto date about the program?
*
Thank you for taking the time to complete this form. Your answers will be collated and the program will, as possible cover the above points suggested and requested. You will be informed of the outcome in the next few weeks via your nominate method of contact above and and an invitation to participate will be sent to you. If you do not wish to receive the invitation please nominate this.
Submit
The Journey Begins
About Leah
Frequently Asked Questions
Books By Leah
Health Management
Consultation bookings
Diabetes - The Guts of It Booking in Page
Gut Health & Food Intolerance
>
Gluten Sensitivity
Resources - download
Privacy Policy
Thoughts To Consider
Thoughts by Leah....
Understand Yourself
>
Suggested Reading
Inspiration Gallery