Stanford Patient Education Rearch Center
Stanford University School of Medicine
SAMPLE QUESTIONNAIRE
DIABETES
You may u all or parts of the questionnaire at no charge without permission Stanford Patient Education Rearch Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 voice (650) 725-9422 fax patienteducation.stanford.edu lf-management@stanford.edu
Name: Address: City, state, zip: Telephone: home ( work ( ) ) __
Today's date:
Date of birth: Sex: Female Male
Background
1. Ethnic origin (check White not Hispanic Black not Hispanic Hispanic only one): Asian or Pacific Islan
der Filipino American Indian/Alaskan Native Other: __________________________
2. Plea circle the highest year of school completed: 1 2 3 4 5 6
(primary)
7 8 9 10 11 12
(high school)
13 14 15 16
(college/university)
17 18 19 20 21 22
(graduate school)
23+
3. Are you currently (check married single
only one): parated divorced widowed
4. Plea indicate below which chronic condition(s) you have: Diabetes type 2 Heart dia Lung dia Diabetes type 1 Type of heart dia: Type of lung dia: High cholesterol High blood pressure
Other chronic condition Specify:
纪念碑
2
General Health
1. In general, would you say your health is: (Circle one) Excellent ...............................1 .3 Fair ........................................4 Poor .......................................5
Symptoms
How much time during the
None of the time A little of the time Some of the time A good bit of the time Most of the time All of the time
1. Were you discouraged by your health problems? .....................................0 2. Were you fearful about your future health? ..........................................0 3. Was your health a worry in your life? ....0 4. Were you frustrated by your health problems? .....................................0
1 1 1 1
蛇瓜的功效与作用2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
5. We are interested in learning whether or not you are affected by fatigue. Plea circle the number below that describes your fatigue in the past 2 weeks:
No fatigue
0
1
2
3
4
5
6
7
8
9
Severe fatigue
10
3
6. We are interested in learning whether or not you are affected by pain. Plea circle the number below that describes your pain in the past 2 weeks.
0
小小少年教案No pain
1
2
3
女校长的私欲4
5
长沙坡子街
6
7
8
9
10
Severe pain
7. We are interested in learning whether or not you are affected by shortness of breath. Plea circle the number below that describes your shortness of breath in the past 2 weeks:
No shortness of breath
正数减负数怎么算0
1
2
3
4
5活着读后感
6
7
8
9
Severe shortness of breath
10
In the PAST WEEK, did you ever have any of the following symptoms… 8. Incread thirst? ................................................................................ 9. Dry mouth? ........................................................................................ 10. Decread appetite? .......................................................................... 11. Naua or vomiting? ..............................................
........................... 12. Abdominal pain?................................................................................ 13. Frequent urination at night? Do you have to get up to urinate 3 or more times a night?……… ......................... 14. Severely high blood sugar (blood gluco readings of 300 mg or higher?) …… ......................... 15. Morning headaches? .......................................................................... No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know 4
In the PAST WEEK, did you ever have any of the following symptoms… 16. Nightmares? ....................................................................................... 17. Night sweats? ..................................................................................... 14. Lightheadedness?............................................................................... 18. Shakiness or weakness? ..................................................................... 19. Inten hunger? .................................................................................. 20. Times when you pasd out fainted consciousness, even for a short time? No No No No No No Yes Yes Yes Yes Yes Yes Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know
Daily Activities
During the past 4 weeks,
Not at all Slightly (Circle one) Moderately Quite a bit Almost totally
1. Has your health interfered with your normal social activities with family, friends, neighbors or groups?..............................0 2. Has your health interfered with your hobbies or recreational activities? ..............0 3. Has your health interfered with your houhold chores? ..............................0 4. Has your health interfered with your errands and shopping? ................................0
1 1 1 1
2 2 2 2
鸡尾酒杯3 3 3 3
4 4 4 4
Your Gluco Testing
1. Do you have a machine to measure your blood sugar (gluco) level? Yes No
2. On how many days in the last week did you test your blood sugar level? (If you were sick in the la
st week, think of the most recent 7 days when you were NOT sick) ________ days 3. On days that you test your blood sugar, how many times do you test on average? _______ times
5
