Diabetes Education – evaluation questionnaire



NEED UNIQUE IDENTIFIER - i.e. study number

Alternatively need name -> confidentiality problem

NEED CENTER NUMBER / NAME

NEED TO ASK - HAVE YOU YET HAD ANY LESSONS? Yes / No

No implies have no yet started any lessons

Yes implies have completed 6 lessons

Please enter today's date

BASELINE QUESTIONS
 

1.                    How would you describe your computer skills:
 

  beginner  intermediate  expert 


2.                     Do you personally have email access at home / work?
 

  Yes  No 


3.                     Do you have on-line Internet / World Wide Web access at home / work?
 

  Yes  No 


4.                     Which level (grade) did you reach at school?
 

 


5.                     Do you have a job?
 

  Yes  No 


5.a                     - If yes, which job?
 

 

 
 
 

SECTION I - self confidence.
 

Qu. 6.                     Please rate how confident you are that you can do the following things at present


(0=not at all confident       6=totally confident)

6.aI can manage my diabetes
0    1    2    3    4    5    6
6.bI can deal with hypoglycemic episodes
0    1    2    3    4    5    6
6.cI can test my blood sugar correctly
0    1    2    3    4    5    6
6.dI can have a trip abroad
0    1    2    3    4    5    6
6.eI can do my usual physical activity
0    1    2    3    4    5    6
6.fI can work out what to eat at home
0    1    2    3    4    5    6
6.gI can eat out at a restaurant
0    1    2    3    4    5    6
6.hI can control my weight
0    1    2    3    4    5    6
6.iI can cope with my diabetes when I am sick
0    1    2    3    4    5    6
6.jI can inject my insulin correctly
0    1    2    3    4    5    6

 

Qu. 7.                     Please select a number which indicates your answer


(0=not at all       6=extremely)

7.aHow concerned are you about your diabetes
0    1    2    3    4    5    6
7.bHow satisfied are you with your blood sugar control
0    1    2    3    4    5    6

 
 
 
 

SECTION II - quality of life and metabolic control.
 
8.aHow many times in the last month have you had a low blood sugar reaction with sweating, weakness, anxiety, trembling, hunger, or headache (hypoglycemia)?
8.bHow many times in the last year have you had severe hypoglycemia with loss of consciousness or need for help?
8.cHow many days in the last month have you had high blood sugar with thirst, dry mouth and skin, nausea or fatigue?
8.d Have you ever been hospitalized for the treatment of diabetes? Yes  No 
8.e - If yes, how many times in the past year?
8.f How often does your diabetes prevent you from doing your normal daily activities?
(0=almost never;  6=almost always)
0    1    2    3    4    5    6

 
 
 
 

SECTION III - social and emotional impact of diabetes on lifestyle.
 

Qu. 9.                     My diabetes and its treatment prevent me from:


(0=strongly disagree; 1=disagree; 3=neutral; 5=agree; 6=strongly agree)

9.aHaving enough money
0    1    2    3    4    5    6
9.bMeeting work responsibilities
0    1    2    3    4    5    6
9.cGoing out or travelling
0    1    2    3    4    5    6
9.dBeing as active as I would like
0    1    2    3    4    5    6
9.eEating foods that I like
0    1    2    3    4    5    6
9.fHaving a good relationship with people
0    1    2    3    4    5    6
9.gGoing to sleep late
0    1    2    3    4    5    6



9.hHaving diabetes makes my life difficult
0    1    2    3    4    5    6
9.iI am afraid of my diabetes
0    1    2    3    4    5    6
9.jI find it hard to believe that I really have diabetes
0    1    2    3    4    5    6
9.kI feel depressed because of my diabetes
0    1    2    3    4    5    6
9.lI have no difficulty taking care of my diabetes
0    1    2    3    4    5    6
9.mI feel inferior to others because of my diabetes
0    1    2    3    4    5    6
9.nI find it hard to do all my things because of my diabetes
0    1    2    3    4    5    6
9.oAll things considered, I feel satisfied with my life
0    1    2    3    4    5    6
9.pI can do anything I set out to do
0    1    2    3    4    5    6
9.qI would like to change many things about myself
0    1    2    3    4    5    6

 
 
 
 

SECTION IV - attitudes towards SMBG.
 

Qu. 10.                     When you do not test your blood glucose, how often is it because:


(0=Never       3=Sometimes         6=Always)

10.aYou forgot
0    1    2    3    4    5    6
10.b You do not believe it is useful
0    1    2    3    4    5    6
10.c The time or place was not appropriate
0    1    2    3    4    5    6
10.dYou do not like to do it
0    1    2    3    4    5    6
10.e You ran out of test materials
0    1    2    3    4    5    6

 
(0=Not relevant   3=Sometimes is relevant       6=Always relevant)

10.fHow important is it that you follow exactly your test schedule for measuring blood glucose
0    1    2    3    4    5    6
10.gHow much does blood glucose (BG) testing help you control your diabetes
0    1    2    3    4    5    6

 
(0=Never      3=Sometimes         6=Always)

10.hHow often do you adjust your insulin dose on the basis of your BG test results
0    1    2    3    4    5    6
10.iHow often do you adjust your diet on the basis of your BG test results
0    1    2    3    4    5    6
10.jHow often do you adjust your physical activity on the basis of your BG test results?
0    1    2    3    4    5    6

 
 
 
 

SECTION V - prior knowledge about diabetes.
 
Qu. 11. Indicate whether each item below is associated with hyperglycemia or hypoglycemia as a sign or symptom.

11.a No glycosuria Hyperglycemia Hypoglycemia
11.b Dry skin and mouth Hyperglycemia Hypoglycemia
11.c Happens slowly Hyperglycemia Hypoglycemia
11.d Increased thirst Hyperglycemia Hypoglycemia

 
Qu. 12. Indicate whether each item below is associated with hyperglycemia or hypoglycemia as a cause.

12.a Too much insulin Hyperglycemia Hypoglycemia
12.b Too much exercise Hyperglycemia Hypoglycemia
12.c Too much food Hyperglycemia Hypoglycemia

 
Qu.13. Insulin reactions (hypoglycemic episodes) are likely to occur:

13.a During vigorous exercise TRUE FALSE
13.b During the peak action of your insulin TRUE FALSE
13.c Just before meals TRUE FALSE
13.d During any of the times mentioned above TRUE FALSE

 
Qu.14. One ml of U-100 insulin contains:

14.a 1 Unit TRUE FALSE
14.b 40 Units TRUE FALSE
14.c 80 Units TRUE FALSE
14.d 100 Units TRUE FALSE

 
 
 
 

SECTION VI - 'what-if' type questions.
 
15.a How many extra Humalog insulin units would you need to add if you increased your lunch by 20 more grams of sugar?


15.b Which of the following is a reasonable action if you double the carbohydrate content of your breakfast (from 20 grams to 40 grams)
(i) Increase your fast acting insulin from 5 units to 6 units
(ii) Increase your fast acting insulin with 3 more units
(iii) Decrease your fast acting insulin by 1 unit
(iv) Decrease your fast acting insulin and add 4 units of Intermediate acting insulin


15.c If I normally inject 6 units of Humalog before breakfast (30 grams of carbohydrate), and my fasting blood glucose this morning is 55 mg/dl (3.1 mmol/l) what should I do?
(i) Only inject 5 units of Humalog
(ii) Inject 7 units of Humalog
(iii) Add 10 grams of carbohydrate to breakfast, and make no change to my insulin regimen
(iv) Add 10 grams of carbohydrate to breakfast and inject 5 units of Humalog
(v) Add 10 grams of carbohydrate to breakfast and inject 7 units of Humalog
(vi) (your option)


15.d If I inject the usual dosage of short-acting insulin (Humulin R, Actrapid) at lunch, but I eat much less than usual, how many hours later is a hypoglycemic episode most likely?


15.e If I have my rapidly-acting insulin (Humalog) injection at 8:00 am and my breakfast at 08:20 am
(i) how many hours after the injection do you think that the peak blood glucose is most likely to occur? hours
(ii) how many hours after the injection do you think that a hypoglycemic episode is most likely to occur? hours


15.f If I run for 20 minutes, 5 hours after a dose of rapidly-acting (Humalog) insulin and my post-exercise blood glucose is 55 mg/dl (3.1 mmol/l), how many grams of carbohydrate should I eat to prevent a hypoglycemic episode? grams


15.g If I feel an impending 'hypo' 2.5 hours after a rapidly-acting (Humalog) insulin injection and my blood glucose is 55 mg/dl (3.1mmol/l),
(i) how many grams of carbohydrate should I eat? grams
(ii) should I continue checking my blood glucose? Yes  No 


16.a Joe has type 1 diabetes and uses a 4 dose regimen (3 rapidly-acting [Humalog] injections and 1 intermediate-acting [NPH] injection at bedtime). His fasting blood glucose is usually in an acceptable range. Last night he increased his usual dose of intermediate-acting insulin with 2 more units, and yet this morning his blood glucose is >300 mg/dl (>16.7 mmol/l).
What should he do?
(i) Increase his morning rapidly-acting insulin
(ii) Increase his morning rapidly-acting insulin and his bedtime intermediate-acting insulin
(iii) Increase his morning rapidly-acting insulin to reduce his blood glucose and re-sample his
blood glucose at 03:00 am the following night
(iv) else (give your own answer)


16.b Last night Joe did not have dinner and did not take his bedtime insulin injection. This morning he has a blood glucose level of 400 mg/dl (22.2 mmol/l) and ketone bodies in his urine.
(i) This is because he could not sleep during the night (insomnia and stress)
(ii) Insulin has accumulated in his body
(iii) There is another explanation apart from food
(iv) else (give your own answer)


16.c Joe's normal blood glucose is always 250 mg/dl (13.8 mmol/l) before breakfast and 120 mg/dl (6.7 mmol/l) 2 hours after dinner. What would you suggest to improve his blood glucose control?
(i) Reduce the rapidly-acting insulin before dinner
(ii) Increase the bedtime intermediate-acting insulin dose
(iii) Increase the rapidly-acting insulin before breakfast
(iv) else (give your own answer)


16.d Bob ate twice his usual amount of carbohydrate at dinner. He had already injected his 10 units of rapidly-acting (Humalog) insulin. What should he do?
(i) Try to vomit
(ii) Add one more rapidly-acting (Humalog) insulin injection (of 3 units more)
(iii) Increase his intermediate-acting (NPH) insulin dose at bedtime
(iv) else (give your own answer)


16.e My doctor asked me to check my blood glucose at 3:00 am. Why?
(i) He wants to know if I am a reliable person
(ii) He has no real purpose
(iii) else (give your own answer)


16.f I had my usual intermediate-acting (NPH) injection at 11:00 pm. If my blood glucose at 03:00 am is 120 mg/dl (6.7 mmol/l), what will happen next?
(i) A hypoglycemic episode at approximately 05:00 am
(ii) Nothing will happen
(iii) Depends on the time course of my last insulin injection
(iv) else (give your own answer)


16.g This evening I will have my nephew's birthday and I will eat more than usual.
What should I do?
(i) Increase my rapidly-acting insulin before dinner
(ii) Increase my intermediate-acting insulin at bedtime
(iii) Do both the above
(iv) Check my blood glucose at 03:00 am
(v) Take 2 injections of rapidly-acting insulin: the first at 10:00 pm and the second at 06:00 am





Dr. Patrizio Tatti – Marino, Roma, Italy
Dr. Eldon D. Lehmann – London, England

on-line html version created by Dr. Gustavo Avitabile – Napoli, Italy

16th April 2000
 
 
 

Acknowledgement

This questionnaire is based in part on questions from the Diabetes Care Profile, from the Michigan Diabetes Research and Training Center (See  Fitzgerald JT, Davis WK, Connell CM, Hess GE, Funnell MM, Hiss RG. Development and validation of the Diabetes Care Profile. Eval. Health Prof. 1996; 19: 208-230).