Form 5 Participant Pretest

NDEP Diabetes HealthSense Participant Pre Survey

The National Diabetes Education Program is trying to find out how well the Diabetes HealthSense website can help people at risk for diabetes and people with 
diabetes. You will help improve Diabetes HealthSense by taking this survey. This survey will take you about 20 minutes to complete. The survey includes 
questions about you and your health. Unless the directions say otherwise, please choose one response for each question. Your survey answers are private. 
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and 
maintaining the data needed, and completing and reviewing the collection of information. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892­7974, ATTN: PRA (0925­xxxx*). Do not return the completed form to this address. 

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NDEP Diabetes HealthSense Participant Pre Survey
ID Code

To keep your responses private an ID code will be created using the following information.  

Please write YOUR first and last initials.
[Example: If your name is Jane Smith choose "J" for your First name initial and "S" for your Last
name initial; If your name is Jane Doe­Smith choose "J" for your First name initial and "D" for
your Last name initial]
First name initial

6

Last name initial

6

What is the MONTH and YEAR of your birth?
[Example: Choose May and 1995 if your birthday is May 22,
1995]
Birth Month
Birth date:

6

Birth Year

6

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NDEP Diabetes HealthSense Participant Pre Survey

Please choose your program location:
j Site 1
k
l
m
n
j Site 2
k
l
m
n
j Site 3
k
l
m
n
j Site 4
k
l
m
n
j Site 5
k
l
m
n

j Site 6
k
l
m
n

j Site 7
k
l
m
n

j Site 8
k
l
m
n

j Site 9
k
l
m
n

j Site 11
k
l
m
n

j Site 12
k
l
m
n

j Site 13
k
l
m
n

j Site 10
k
l
m
n

j Site 14
k
l
m
n

j Site 15
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey
Resources

1. How often do you look for information on preventing or managing diabetes?
j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n
j Often
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey

2. Where have you received or found information about diabetes prevention and management? (Choose one or more)
c Health care provider
d
e
f
g

c Mass media (such as TV, radio, newspaper)
d
e
f
g
c Social media (such as Facebook)
d
e
f
g
c Internet
d
e
f
g
c Mail
d
e
f
g

c Friends/family
d
e
f
g

c Diabetes education class or program
d
e
f
g
c Professional associations
d
e
f
g
c None of the above
d
e
f
g

Page 5

NDEP Diabetes HealthSense Participant Pre Survey
Resources

3. In the last month, have you participated in a diabetes education class or program? (For example, attended one or more
individual or group classes or meetings with a diabetes educator, nurse or dietitian?)
j No
k
l
m
n

j Yes
k
l
m
n

If yes, please specify 

5

6

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NDEP Diabetes HealthSense Participant Pre Survey
Resources

4. How would you describe your experience with these NDEP resources?
Never heard of it

Heard of it but do 
not have it

Have it but have  Have it and used it Have it and use it a 
not used it

once

lot

a. Small Steps. Big Rewards: Your GAMEPLAN to Prevent Type 2 Diabetes

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Choose More than 50 Ways to Prevent Diabetes

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Paso a Paso

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Get Real! You Don't Have to Knock Yourself Out to Prevent Diabetes

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 7

NDEP Diabetes HealthSense Participant Pre Survey
Resources

5. How often in the past month have you used the…
2­3 times this 

Once this month

a. NDEP Diabetes HealthSense Website

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. The American Diabetes Association Website (Diabetes.org)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

month

Once a week

More than once a 

Never

week

Page 8

NDEP Diabetes HealthSense Participant Pre Survey
Risk

6. Has a doctor or other health professional ever told you that you: (Choose one or more)
c Have Type 1 diabetes
d
e
f
g
c Have Type 2 diabetes
d
e
f
g

c Have prediabetes or borderline diabetes
d
e
f
g

c Have high blood glucose, impaired fasting glucose, or impaired glucose tolerance?
d
e
f
g
c Are at risk for diabetes
d
e
f
g

7. Which, if any, of the following is true for you? (Choose one or more)
c I have a mother, father, sister, or brother with diabetes
d
e
f
g

c I have been told by a doctor or other health professional that I have high blood pressure
d
e
f
g
c I have been told by a doctor or other health professional that I have high cholesterol
d
e
f
g
c I am NOT physically active
d
e
f
g

c I was diagnosed with gestational diabetes during any of my pregnancies
d
e
f
g
c I have given birth to a baby weighing 9 pounds or more
d
e
f
g

c I smoke
d
e
f
g

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

8. Which of the following can quickly raise your blood glucose?
j Baked chicken
k
l
m
n

j Swiss cheese
k
l
m
n

j Baked potato
k
l
m
n

j Peanut butter
k
l
m
n

9. Eating foods lower in saturated and trans fat decreases your risk for:
j Nerve disease
k
l
m
n

j Kidney disease
k
l
m
n
j Heart disease
k
l
m
n
j Eye disease
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

10. The A1C is a measure of your average blood glucose for the past:
j Day
k
l
m
n

j Week
k
l
m
n

j 2­3 months
k
l
m
n
j 6 months
k
l
m
n

11. Which should not be used to treat low blood glucose?
j 3 hard candies
k
l
m
n

j 1/2 cup orange juice
k
l
m
n
j 1 cup diet soft drink
k
l
m
n
j 1 cup skim milk
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

12. Which of the following is the least amount of physical activity you should do to prevent or manage diabetes?
j 30 minutes of activity, five times a week (or 150 minutes per week)
k
l
m
n
j 10 minutes of activity, seven days a week (or 70 minutes per week)
k
l
m
n
j 45 minutes of activity, six days a week (or 270 minutes per week)
k
l
m
n

13. Which of the following exercise programs includes a mix of strength, flexibility and aerobic activities?
j Walking, running, and swimming
k
l
m
n

j Lifting weights, push­ups, sit­ups
k
l
m
n

j Walking, lifting weights, stretching
k
l
m
n

j Stretching, deep breathing, meditating
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

14. The best way to lose weight is to:
j Limit amount of physical activity
k
l
m
n
j Increase portion sizes
k
l
m
n

j Combine healthy eating and exercise
k
l
m
n

j Reduce dietary fat without reducing calories
k
l
m
n

15. Which of the following factors contribute to a person’s weight? (Choose one or more)
c Family history and genetics
d
e
f
g
c Environment
d
e
f
g
c Metabolism
d
e
f
g

c Behavior or habits
d
e
f
g

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

16. The best way to take care of your feet is to:
j Check them each day for cuts, blisters and swelling
k
l
m
n
j Massage them with alcohol each day
k
l
m
n
j Soak them for one hour each day
k
l
m
n

j Buy shoes a size larger than usual
k
l
m
n

17. People with diabetes whose blood glucose is out of control are at greater risk of which complications? (Choose one or
more)
c Serious eye problems
d
e
f
g
c Circulation problems
d
e
f
g
c Kidney Problems
d
e
f
g
c Allergy problems
d
e
f
g
c Gum disease
d
e
f
g

c Heart attack or stroke
d
e
f
g

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

18. Which of the following may be a sign of an emotional low and/or depression in a person with diabetes?
(Choose one or more)
c Sleeps most of the day
d
e
f
g

c Does not have an interest or find pleasure in activities
d
e
f
g
c Does not feel in control of their diabetes
d
e
f
g

c Discusses diabetes care with family and friends
d
e
f
g

19. Depression can raise your blood glucose by causing you to eat too much, do too little, and reduce your motivation to
take care of yourself.
j True
k
l
m
n

j False
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey

20. Which of the following steps are important ways to help you achieve your goals? (Choose one or more.)
c Making a plan with realistic goals
d
e
f
g
c Tracking progress
d
e
f
g
c Avoiding rewards
d
e
f
g

c Using a support system
d
e
f
g

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NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

21. For each statement, please check the option that best describes your behaviors.
Have you:
No, and I do not 
plan to

No, but I plan to 

No, but I plan to 

Yes, I started this 

within the next 6 

within the next 

less than 6 months 

Yes, I have been 
doing this for 6 

months

month

ago

months or longer

a. Looked for resources to help you learn about or help you manage your diabetes?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Set a healthy eating or weight loss goal?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Reduced the amount of fat in your diet?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Reduced the number of calories you eat?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

e. Kept track of what you eat and drink most days of the week?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

f. Set a physical activity goal?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

g. Fit exercise into your daily routine (for example, took the stairs instead of elevator, etc)?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

h. Exercised for 30 minutes at least 5 days a week?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

i. Kept track of your physical activity most days of the week?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 17

NDEP Diabetes HealthSense Participant Pre Survey
Knowledge and Behaviors

22. Are you seriously thinking of quitting smoking?
j I have never smoked or I quit more than 6 months ago
k
l
m
n
j I am not thinking of quitting
k
l
m
n

j I plan to quit within the next 6 months
k
l
m
n
j I plan to quit within the next 30 days
k
l
m
n
j I quit within the last 6 months
k
l
m
n

Page 18

NDEP Diabetes HealthSense Participant Pre Survey

Please indicate the degree to which each of the following items may be bothering you. If you feel that a particular item is not a bother or a problem for you, you would check “1.” If it is very 
bothersome to you, you might check “6.”  

23. How much do the following feelings bother you in your life?
Not a problem  
1

Serious 

problem  

2

3

4

5

6

a. Feeling overwhelmed by the demands of living with diabetes or at risk of developing diabetes.

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Feeling that you are often failing with your diabetes or diabetes prevention regimen.

j
k
l
m
n

j
k
l
m
n

j
k
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m
n

j
k
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m
n

j
k
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m
n

j
k
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m
n

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NDEP Diabetes HealthSense Participant Pre Survey

24. How confident do you feel that you can…
Not at all 

Totally 

confident  

confident  

1

2

3

4

5

6

a. Find resources to help you learn about or manage your diabetes or your risk for diabetes?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Set a healthy eating or weight loss goal?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Reduce the amount of fat in your diet?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Reduce the number of calories you eat?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

e. Keep track of what you eat and drink most days?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

f. Set a physical activity goal?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

g. Fit exercise into your daily routine (for example, take the stairs instead of elevator, etc)?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

h. Exercise for 30 minutes at least 5 days a week?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

i. Keep track of your physical activity most days?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

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NDEP Diabetes HealthSense Participant Pre Survey

25. How confident do you feel that you can follow your health care provider’s recommendations for…
Not at all 

Totally 

confident 

Confident 

1

2

3

4

5

6

a. Checking your blood glucose.

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Taking medications for diabetes, blood pressure, cholesterol, or heart disease?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Checking your blood pressure?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Checking your feet for redness or sores?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
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m
n

j
k
l
m
n

Does not 
apply

Page 21

NDEP Diabetes HealthSense Participant Pre Survey

26. Think back over the past month. How often did you…
Never

Rarely

Sometimes

Often

All of the time

a. Fill half of your plate with fruits and vegetables at each meal?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Reduce the amount of fat in your diet?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Reduce the number of calories you eat?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Reduce the number of unhealthy snacks and desserts/sweets you eat?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

e. Reduce your portion sizes?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

f. Choose drinks without added sugar like diet sodas and unsweetened tea?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

g. Follow your diet goals and plans?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

h. Track your diet to measure progress?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 22

NDEP Diabetes HealthSense Participant Pre Survey

27. Think back over the past month. How often did you…
Never

Rarely

Sometimes

Often

All of the time

a. Exercise for 30 minutes at least 5 days a week?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b. Fit exercise into your daily routine (for example, take stairs instead of elevator, etc)?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Do different types of exercises such as stretching, strength training, walking?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Follow your exercise goals and plans?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

e. Track your exercise to measure progress?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 23

NDEP Diabetes HealthSense Participant Pre Survey

28. Think back over the past month. How often did you do the following to cope with stress and emotions?
Never

Rarely

Sometimes

Often

a. Exercise?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

b.Use relaxation techniques such as meditation or deep breathing?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Participate in a support group?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Use the support of family and friends?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

e. Participate in enjoyable hobbies?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

f. Participate in faith­based activities?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 24

NDEP Diabetes HealthSense Participant Pre Survey

29. Think back over the past month. How often did you follow your health care provider’s recommendations for…
Never

Rarely

Sometimes

Often

a. Checking your blood glucose?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

All of the time Does not apply

j
k
l
m
n

j
k
l
m
n

b. Taking medications for diabetes, blood pressure, cholesterol, or heart disease?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

c. Checking your blood pressure?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

d. Checking your feet for redness or sores?

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 25

NDEP Diabetes HealthSense Participant Pre Survey
About You

30. What is your gender?
j Female
k
l
m
n
j Male
k
l
m
n

31. How old are you?
j Under 25
k
l
m
n
j 25­34
k
l
m
n
j 35­44
k
l
m
n
j 45­54
k
l
m
n
j 55­64
k
l
m
n
j 65+
k
l
m
n

Page 26

NDEP Diabetes HealthSense Participant Pre Survey
About You

32. What is your height? ( feet and inches )
Feet

Inches

6

Height

6

33. What is your weight? ( lbs )

Page 27

NDEP Diabetes HealthSense Participant Pre Survey
About You

34. Are you Hispanic or Latino?
j No
k
l
m
n

j Yes
k
l
m
n

35. What is your race? (Choose one or more)
c Black or African American
d
e
f
g
c White
d
e
f
g

c American Indian or Alaska Native
d
e
f
g

c Native Hawaiian or other Pacific Islander
d
e
f
g
c Asian
d
e
f
g

36. Is English your primary language?
j No
k
l
m
n

j Yes
k
l
m
n

Page 28

NDEP Diabetes HealthSense Participant Pre Survey
About You

37. What is the highest level of education you have completed?
j Some high school (grades 9­11)
k
l
m
n
j High school degree or GED
k
l
m
n
j Associate degree (2­year)
k
l
m
n
j College degree (4­year)
k
l
m
n
j Graduate degree
k
l
m
n

38. Please check the category that represents your annual household income.
j Less than $15,000
k
l
m
n
j $15,000­$35,000
k
l
m
n
j $36,000­$50,000
k
l
m
n
j $51,000­$75,000
k
l
m
n
j Over $75,000
k
l
m
n

Page 29

NDEP Diabetes HealthSense Participant Pre Survey

About You

39. How often do you use the internet at home?
j Rarely or Never
k
l
m
n

j 2­3 times a month
k
l
m
n
j Once a week
k
l
m
n

j 2­3 times a week
k
l
m
n

j Daily
k
l
m
n

40. How often do you need to have someone help you understand written instructions, pamphlets, or other materials from
your doctor or pharmacy?
j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n
j Often
k
l
m
n

j Always
k
l
m
n

Page 30

NDEP Diabetes HealthSense Participant Pre Survey

Thank you for completing our survey. 

Page 31