Defend Against Diabetes New survey
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1
. Thank you! Please check what you would like (you may select more than one).
Thank you! Please check what you would like (you may select more than one).
Booklet: Healthier Eating One Step At a Time
Booklet: Top 5 Ways to Stop Diabetes and Get Healthy Right Now!
Cookbook
Packet: Your Game Plan for Preventing Type 2 Diabetes
2
. What is your name and mailing address?
What is your name and mailing address?
Name:
Address:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
3
. If you would like to join our email list, please enter your email address below
If you would like to join our email list, please enter your email address below
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4
. Please answer the following questions to help us improve our campaign.
Did you take the diabetes risk assessment quiz?
Please answer the following questions to help us improve our campaign. Did you take the diabetes risk assessment quiz?
Yes
No
If no, why not?
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5
. What do you like or dislike about the website? What would you improve?
What do you like or dislike about the website? What would you improve?
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6
. Was this website useful to you?
Was this website useful to you?
Yes, a lot
Yes, a little
No
If no, why not?
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7
. Before going on the Defend Against Diabetes website, did you know how diabetes can be prevented?
Before going on the Defend Against Diabetes website, did you know how diabetes can be prevented?
Yes
No
Not Sure
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8
. After going on the Defend Against Diabetes website, do you know how diabetes can be prevented?
After going on the Defend Against Diabetes website, do you know how diabetes can be prevented?
Yes
No
Not Sure
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9
. Before you went on the Defend Against Diabetes website, what did you think about changing your behavior to be more healthy?
Before you went on the Defend Against Diabetes website, what did you think about changing your behavior to be more healthy?
Not likely to change my current behavior
Thinking about making a change (in the next 6 months)
Ready to make a change in the next month
I have already made a change (in the last 6 months) and want to keep moving ahead
I have made a change more than 6 months ago and need to maintain it
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10
. After you went on the Defend Against Diabetes website and learned your risk of type 2 diabetes, now what do you think about changing your behavior to be more healthy?
After you went on the Defend Against Diabetes website and learned your risk of type 2 diabetes, now what do you think about changing your behavior to be more healthy?
Not likely to change my current behavior
Thinking about making a change (in the next 6 months)
Ready to make a change in the next month
I have already made a change (in the last 6 months) and want to keep moving ahead
I have made a change more than 6 months ago and need to maintain it
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