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Diabetes Client Enrollment Survey 202103

Diabetes Self Management Client Enrollment

Welcome! Please take this enrollment form Diabetes Self Management.

These programs are sponsored by the Center for Disease Control and we would like to collect some information to evaluate the effectiveness of the programs. If you wish to leave a question blank, you may. The page will refresh and warn you that a question was not completed. Simply click 'Next' again and you will be taken to the next page in the survey. All data is encrypted and stored securely.
Name *This question is required.
This question requires a valid email address.
Mailing Address  *This question is required.
2. Did your doctor or other health care provider suggest you attend this program?
YesNo
This question requires a valid number format.
4. Are you_______
5. Are you of Hispanic, Latino, or Spanish origin?
6. What is your race / ethnicity?
7. Please answer the following questions:
Space Cell YesNo
Are you deaf or do you have serious hearing difficulty?
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Do you live alone?
Have you ever served in the military?
During the past year, did you provide regular care or assistance to a friend or family member who has a long-term health problem or disability?
8. What is the highest grade or year of school you completed?
Some elementary, middle, or high schoolHigh school graduate or GEDSome college or technical schoolCollege 4 years or more
9. In general, would you say your health is:
ExcellentVery GoodGoodFairPoor
10. Please indicate if a healthcare provider has ever told you that you have any of the following chronic conditions:
11. Please answer the following questions:
Space Cell YesNo
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shop?
Do you have difficulty walking on stairs?
Do you have difficulty dressing or bathing?
12. How often do you feel lonely or isolated from those around you?
AlwaysOftenSometimesRarelyNever
13. What is your health insurance coverage?
14. What is your level of confidence in managing your chronic condition(s)? (Please circle one number.)
 012345678910 
Not at all confidentVery Confident
15. In the past week, did you ever forget to take your medicine?
YesNoI don't need to take medications
16. In the past week, how many days did you exercise for at least 30 minutes? (Please circle one number.)
0 day
3/4 times a week
7 days of the week
17. How often do you examine Nutrition Facts labels to aid in making food choices? (Please circle one number.)
NeverOccasionallyAbout half timeUsuallyAlways
18. When you visit your doctor, nurse or other health care provider, how often do you prepare a list of questions? (Please circle one number.)
NeverOccasionallyAbout half timeUsuallyAlways