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Thank you for being a participant in the Diabetes Education Workshop. As we begin the program, we would like to request some general information from you to understand the needs of the participants. We estimate this will take you less than 10 minutes to complete. All information you provide will be treated in a confidential manner. Your agreement indicates your consent to respond to the survey questions.
Participant Information

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* 1. In order to match your pre-program responses to your post-program responses, please fill out the information below.

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* 2. Date of Diabetes Education Workshop

Date

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* 3. What is your Zip Code? 

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* 4. What is your age? 

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* 5. Are you of Hispanic or Latino origin or descent? (Please choose only one)

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* 6. Which race best describes you?  (Please choose only one) 

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* 7. Do you identify your gender as:

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* 8. How much total combined money did all people living in your home earn last year? (Please only choose one)

General Health Questions 

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* 9. How would you rate your health? (Please only choose one)

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* 10. What year were you diagnosed with diabetes?

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* 11. What type of diabetes were you diagnosed with?

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* 12. What was your highest blood sugar in the last week?

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* 13. What was your lowest blood sugar in the last week?

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* 14. When was your last HbA1C? 

Date

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* 15. What was your last HbA1C result? 

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* 16. When was you last appointment with your healthcare provider?

Date

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* 17. When was the last time you visited the emergency room?

Date

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* 18. When was the last time you were a patient in the hospital?

Date

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* 19. Before taking this class, did you know

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What diabetes is?
How to plan healthy meals?
How exercise affects your blood sugar?
How to take diabetes medications correctly?
How to test your own blood sugar?
What HbA1c is?
How to treat low blood sugar?
Five complications of diabetes?
How to lower risk of complications?
How to do proper foot care?
How to cope with stress?
How often to see your healthcare provider or diabetes educator?
What community resources are available?

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* 20. What resources do you currently use for diabetes education? (Check all that apply)

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