Diabetes Education Workshop - Pre-Program Evaluation

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.

First Name

Last Name

Date of Birth MMDDYY

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* 2. Date of Diabetes Education Workshop

Enter the start date of the workshop you attended.

Date

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* 3. What is your Zip Code?

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* 4. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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

Yes, Hispanic or Latino

No, not Hispanic or Latino

Prefer not to answer

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

More than one race

African American or Black

American Indian or Alaska Native

Asian or Asian American

Native Hawaiian or other Pacific Islander

White or Caucasian

Prefer not to answer

Other (please specify)

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* 7. Do you identify your gender as:

Female

Male

Transgender Female to Male

Transgender Male to Female

Other /Gender non-Conforming

Prefer not to answer

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

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

General Health Questions

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

Excellent

Good

Fair

Poor

Very poor

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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?

Please enter the date of 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?

Please enter the date of your last appointment

Date

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

Skip question if not applicable.

Date

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

Skip question if not applicable.

Date

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* 19. Before taking this class, did you know

	Yes	No	Need more information
What diabetes is?	What diabetes is? Yes	What diabetes is? No	What diabetes is? Need more information
How to plan healthy meals?	How to plan healthy meals? Yes	How to plan healthy meals? No	How to plan healthy meals? Need more information
How exercise affects your blood sugar?	How exercise affects your blood sugar? Yes	How exercise affects your blood sugar? No	How exercise affects your blood sugar? Need more information
How to take diabetes medications correctly?	How to take diabetes medications correctly? Yes	How to take diabetes medications correctly? No	How to take diabetes medications correctly? Need more information
How to test your own blood sugar?	How to test your own blood sugar? Yes	How to test your own blood sugar? No	How to test your own blood sugar? Need more information
What HbA1c is?	What HbA1c is? Yes	What HbA1c is? No	What HbA1c is? Need more information
How to treat low blood sugar?	How to treat low blood sugar? Yes	How to treat low blood sugar? No	How to treat low blood sugar? Need more information
Five complications of diabetes?	Five complications of diabetes? Yes	Five complications of diabetes? No	Five complications of diabetes? Need more information
How to lower risk of complications?	How to lower risk of complications? Yes	How to lower risk of complications? No	How to lower risk of complications? Need more information
How to do proper foot care?	How to do proper foot care? Yes	How to do proper foot care? No	How to do proper foot care? Need more information
How to cope with stress?	How to cope with stress? Yes	How to cope with stress? No	How to cope with stress? Need more information
How often to see your healthcare provider or diabetes educator?	How often to see your healthcare provider or diabetes educator? Yes	How often to see your healthcare provider or diabetes educator? No	How often to see your healthcare provider or diabetes educator? Need more information
What community resources are available?	What community resources are available? Yes	What community resources are available? No	What community resources are available? Need more information

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

None

Website

Magazines

Mobile apps

Healthcare professional

Health education workshops

Other (please specify)