Diabetes Education Workshop - Post Program Evaluation Survey

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* 1. Data will be de-identified when reported. 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. After taking this class, do 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

Please indicate which behaviors you plan on changing after taking this class

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* 5. Healthy Eating (Check all that apply)

Follow my eating schedule better

Eat healthier food

Overeat less often

Spread out carbs evenly throughout day 

Increase vegetable servings to 2 servings/day 

Decrease fat servings by 2x/day

Other (please specify)

None of the above, I am already eating healthy.

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* 6. Physical Activity (Check all that apply)

Increase how often I am active (ex 3 times a week)

Start walking regularly

Increase how long I am active (ex 30 min)

Add new exercises to my routine (ex swimming, yoga, workout videos)

Other (please specify)

None of the above, I am already physically active.

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* 7. Monitoring & Controlling Blood Sugar (Check all that apply)

Check and record my blood sugar regularly

Have A1C checked every 3 months 

Prevent and treat high blood sugars

Prevent and treat low blood sugars

Manage diabetes when sick

Other (please specify)

None of the above, I am already monitoring and recording my results regularly.

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* 8. Medication Usage (Check all that apply)

Take medications as prescribed

Give my own insulin injection

Set a reminder to take medications

Keep a list of medications, dosages, and what they are prescribed for to review with healthcare providers

Keep a list of over the counter medications being taken

Other (please specify)

None of the above.

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* 9. Healthy Coping (Check all that apply)

Relaxation techniques to deal with difficult emotions related to diabetes

Ask for support from my healthcare providers 

Ask for support from family/friends 

Membership to diabetes organization/magazine

Physician visit every 3 months

Attend a support group

Other (please specify)

None of the above.

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* 10. Reducing Risks and Complications (Check all that apply)

Get prevention tips

Stop smoking/Take smoking cessation class (use patches, gum, etc)

Inspect feet daily 

Have healthcare provider check feet/See a podiatrist

Lose weight 

Monitor and control blood pressure

Talk to healthcare provider about pregnancy and diabetes

Other (please specify)

None of the above.

Please check the resources listed that you may be interested in using after attending our Diabetes Education class:

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* 11. Websites (Check all that apply)

http://www.diabetes.org-/ American Diabetes Association

http://www.diabetesselfmanagment.com/ Diabetes Self-Management

http://www.eatright.org-academy/ Academy of Nutrition and Dietetics

http://www.diabetes.niddk.nih.gov-national/ Diabetes Information Clearinghouse

http://www.nkdep.nih.gov-national/ National Kidney Disease Education Program

http://www.nkdep.nih.gov/ National Eye Health Education Program

http://www.cdc.gov/ Centers for Disease control

http://www.americanheart.org-american/ American Heart Association

Other (please specify)

None of the above

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* 12. Magazines (Check all that apply)

Diabetes Spectrum

Diabetes Forecast

Cooking Light

Diabetic Living

Diabetes Self Management

Other (please specify)

None of the above

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* 13. Mobile apps (Check all that apply)

CalorieKing

MyFitnessPal

Figwee

Lose It!

Fooducate

Glucose Buddy

Tidepool

Glooko

MySugr

Other (please specify)

None of the above

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* 14. Health Education Events (Check all that apply)

TGH Diabetes Support Group "Sweet Ones"

TGH Community Health Education & Self Management Programs

TGH Diabetes Self Management Education Seminar

Faith Based Health Events

Local YMCA/Gym

Community Health Fairs

Other (please specify)

None of the above

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* 15. Schedule Follow-up with (Check all that apply)

Registered Dietitian for individual consultation

Healthcare provider's office for appointment/ support services

My health insurance company

Local pharmacy about diabetes education programs/support

My Glucose meter company about diabetes support programs/materials

My church or religious organization for health education programs/support

Other (please specify)

None of the above

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* 16. Would you recommend this workshop to family or friends with diabetes?

Yes

If no, why?

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* 17. Are you interested in the 2 day Diabetes Self Management Education Class?

Yes

Would like additional information

If no, why?

Diabetes Education Workshop - Post Program Evaluation

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* 1. Data will be de-identified when reported. 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

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* 3. What is your Zip Code?

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* 4. After taking this class, do you know

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* 5. Healthy Eating (Check all that apply)

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* 6. Physical Activity (Check all that apply)

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* 7. Monitoring & Controlling Blood Sugar (Check all that apply)

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* 8. Medication Usage (Check all that apply)

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* 9. Healthy Coping (Check all that apply)

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* 10. Reducing Risks and Complications (Check all that apply)

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* 11. Websites (Check all that apply)

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* 12. Magazines (Check all that apply)

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* 13. Mobile apps (Check all that apply)

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* 14. Health Education Events (Check all that apply)

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* 15. Schedule Follow-up with (Check all that apply)

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* 16. Would you recommend this workshop to family or friends with diabetes?

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* 17. Are you interested in the 2 day Diabetes Self Management Education Class?

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* 18. Please provide any feedback you would like to share.