Attachment B -- Patient Questionnaire -- English Version

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Form Approved
OMB No. 0935-0179
Exp. Date 07/31/2014

urvey for Diabetes Patients

1. How long ago were you diagnosed with type 2 diabetes? Circle one answer.

• Less than 1 year

• 1-5 years

• 6-10 years

• Over 10 years

2. What are the biggest challenges you have to following your treatment plan? Circle up to two answers. Write an X next to the most important answer, if you chose two answers.

• Cost

• Getting medication

• Taking the medication as directed

• Side effects

• Getting to the doctor regularly

• Changes to diet

• Getting to a healthy weight

• Other (write your answer) ___________________

3. Is the telenovela information presented in a natural, logical manner? Circle one answer.

• Yes

• No

4. Would you recommend this telenovela to a family member or friend? Circle one answer.

• Yes

• No

5. Is there anything you particularly like or dislike about the telenovela? Circle your answers.

• Characters Like Dislike

  • Any character in particular? ________________

• General Story Like Dislike

• Cliffhangers Like Dislike

• Music Like Dislike

• Narration Like Dislike

• Other (write your answer) ________________________________

6. After watching the telenovela, do you feel more able to ask questions about your medication or treatment? Circle one answer.

• Yes

• No

7. Besides diabetes clinics like this one, where else is a good place to see this telenovela? Circle as many answers as you want.

• Doctor’s office

• Television

• Internet – computer

• Mobile phone

• Other (write your answer) _______________________

8. In your opinion, how effective is this idea of a telenovela to communicate the importance of taking diabetes medications? Circle one answer.

• Very effective

• Effective

• Not effective

9. What other topics might be good for this telenovela format? Circle as many answers as you want.

• Managing heart disease

• People who help to take care of patients (caregiver)

• Treating depression

• Other (write your answer) __________________________

The questions below will be used only for statistical purposes and will not be used to identify or contact you.

1. Circle one: Are you

• Male

• Female

2. Circle one: Is your age group

• Under 30 – Write your age here:_________

• 31-40 years old

• 41-50 year old

• 51-70 years old

• Over 71 years old

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0179) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.