Socio-demographic profile
Serial No: ______
Age (in years): ______
Gender:
Male Female Others
Education:
Illiterate Just literate Primary School
Middle School Secondary School Higher Secondary
Graduation Post Graduation
Occupation:
Unemployed Unskilled Semiskilled
Skilled Semiprofessional Professional
Retired Homemaker
Income:
Total family income: _______________ Number of Members: ________________
Religion:
Hinduism
Christianity
Islam
Sikh
Other (specify: ____________)
Residence:
Urban
Rural
Marital Status:
Married
Unmarried
Divorced
Separated
Widow/Widower
Types of Family
Joint ____ Nuclear _______
BODY MASS INDEX
Height (in cm): ______________ Weight (in kg): ______________
Body Mass Index: _____________
Date/yr of diagnosis: ________________________
Date/yr of initiation of treatment: ______________________
Blood pressure- _____________________ CBG _________________
FBS___________ PPBS___________________ HBA1C _________________ (LAST 3 MONTH)
Diabetic Complications:
Neuropathy
Nephropathy
Retinopathy
Foot ulcer
Substance Abuse:
Alcohol
Smoke
Tobacco
Others (specify: _______________________)
Frequency of Use:
Daily ________ Weekly___________ Occasionally___________
Diabetes Mellitus Type 2 Self Help Care Questionnaire
Diet
How many of the last SEVEN DAYS have you followed a healthful eating plan?
0 1 2 3 4 5 6 7
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
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
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
Exercise
On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity? (Total
minutes of continuous activity, including walking)
0 1 2 3 4 5 6 7
On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as 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
Blood Sugar Testing
On how many of the last SEVEN DAYS did you test your blood sugar?
0 1 2 3 4 5 6 7
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
Foot Care
On how many of the last SEVEN DAYS did you check your feet?
0 1 2 3 4 5 6 7
On how many of the last SEVEN DAYS did you inspect the inside of your shoes?
0 1 2 3 4 5 6 7
Smoking
Have you smoked a cigarette—even one puff—during the past SEVEN DAYS?
0. No
1. Yes. If yes, how many cigarettes did you smoke on an average day? Number of cigarettes:
_____________
Additional Items for the Expanded Version of the Summary of Diabetes Self-Care Activities.
Self-Care Recommendations
1A. Which of the following has your health care team (doctor, nurse, dietitian, or diabetes educator) advised
you to do? Please check all that apply:
a. Follow a low-fat eating plan
b. Follow a complex carbohydrate diet
c. Reduce the number of calories you eat to lose weight.
d. Eat lots of food high in dietary fiber
e. Eat lots (at least 5 servings per day) of fruits and vegetables
f. Eat very few sweets (for example: desserts, non-diet sodas, candy bars)
g. Other (specify):
h. I have not been given any advice about my diet by my health care team.
2A. Which of the following has your health care team (doctor, nurse, dietitian or diabetes educator) advised
you to do? Please check all that apply
a. Get low level exercise (such as walking) on a daily basis.
b. Exercise continuously for a least 20 minutes at least 3 times a week.
c. Fit exercise into your daily routine (for example, take stairs instead of elevators, park a block away
and walk, etc.)
d. Engage in a specific amount, type, duration and level of exercise
e. Other (specify):
f. I have not been given any advice about exercise by my health care team
3A. Which of the following has your health care team (doctor, nurse, dietician, or diabetes educator) advised
you to do? Please check all that apply
a. Test your blood sugar using a drop of blood from your finger and a color chart
b. Test your blood sugar using a machine to read the results
c. Test your urine for sugar
d. Other (specify):
e. I have not been given any advice either about testing my blood or urine sugar level by my health
care team.
4A. Which of the following medications for your diabetes has your doctor prescribed? Please check all that
apply.
a. An insulin shot 1 or 2 times a day.
b. An insulin shot 3 or more times a day
c. Diabetes pills to control my blood sugar level.
d. Other (specify):
e. I have not been prescribed either insulin or pills for my diabetes
Diet
On how many of the last SEVEN DAYS did you space carbohydrates evenly through the day?
0 1 2 3 4 5 6 7
Medication
How many of the last SEVEN DAYS, did you take your recommended diabetes medication?
0 1 2 3 4 5 6 7
(or)
On how many of the last SEVEN DAYS did you take your recommended insulin injections?
0 1 2 3 4 5 6 7
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
Foot Care
On how many of the last SEVEN DAYS did you wash your feet?
0 1 2 3 4 5 6 7
On how many of the last SEVEN DAYS did you soak your feet?
0 1 2 3 4 5 6 7
On how many of the last SEVEN DAYS did you dry between your toes after washing?
0 1 2 3 4 5 6 7
Smoking
At your last doctor’s visit, did anyone ask about your smoking status?
0.Yes
1.No
If you smoke, at your last doctor’s visit, did anyone counsel you about stopping smoking or offer to refer you to
a stop-smoking program?
0. Yes
1 .No
3. Do not Smoke.
When did you last smoke a cigarette?
More than two years ago, or never smoked
One to two years ago
One to three months ago
Within the last month
Today
