Form #6 Form #6 Summary of Diabetes Self-Care Activities Survey

Attachment F: Summary of Diabetes Self-Care Activities (SDSCA) Survey 2

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ttachment H: Summary of Diabetes Self-Care Activities (SDSCA) Survey

Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow

Summary of Diabetes Self-Care Activities Survey

Public reporting burden for this collection of information is estimated to average 18 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-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Thank you for your cooperation in completing this survey. This questionnaire has been designed to gather information about your diabetes self-care over the past 7 days. When completing it, you should think about how you feel and what you think, based on your experiences. Some questions may sound similar to others, but please still try to answer all of the questions. You can leave blank any questions that you do not want to answer. Your responses will be kept confidential under Section 944(c) of the Public Health Service Act.  42 U.S.C. 299c-3(c).  That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied.

Your care team will never see your individual responses.

The questions below ask you about your diabetes self-care activities during the past 7 days. If you were sick during the past 7 days, please think back to the last 7 days that you were not sick. If you are unable to complete the questions on your own, please ask for assistance. Please check only one box for each question.

A. Diet Number of Days

1. On average, over the past month, how many days per week have you followed your eating plan?	0	1	2	3	4	5	6	7
2. On how many of the last seven days did you eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
3. On how many of the last seven days did you eat high fat foods such as red meat or full-fat dairy products?	0	1	2	3	4	5	6	7
4. On how many of the last seven days did you space carbohydrates evenly through the day?	0	1	2	3	4	5	6	7
5. On how many of the last seven days have you followed a healthful eating plan?	0	1	2	3	4	5	6	7

B. Exercise Number of Days

1. On how many of the last seven days did you participate in at least 30 minutes of physical activity?	0	1	2	3	4	5	6	7
2. On how many of the last seven days did you participate in a specific exercise session (such as such swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7

C. Blood Sugar Testing Number of Days

1. On how many of the last seven days did you test your blood sugar?	0	1	2	3	4	5	6	7
2. On how many of the last seven days did you test your blood sugar the number of times recommended by your health care provider?	0	1	2	3	4	5	6	7

D. Smoking

Have you smoked a cigarette—even one puff—during the past seven days? Yes No

If yes, how many cigarettes did you smoke on an average day? ___________

E. Foot Care Number of Days

1. On how many of the last seven days did you check your feet?	0	1	2	3	4	5	6	7
2. On how many of the last seven days did you inspect the inside of your shoes?	0	1	2	3	4	5	6	7

F. Medications Number of Days

1. On how many of the last seven days, did you take your recommended diabetes medication?	0	1	2	3	4	5	6	7
2. Do you take Insulin? If Yes, On how many of the last seven days did you take your recommended insulin injections?	0	1	2	3	4	5	6	7
3. Do you take pills to lower your blood sugar? If Yes, On how many of the last seven days did you take your recommended number of diabetes pills?	0	1	2	3	4	5	6	7