Name

:
Age:
Income:
Level of education:
When/if dx with diabetes:
The most important thing about managing diabetes:
Waist circumference:
Have you ever smoked tobacco? Do you smoke now?
Are you currently taking any medication?
Signs/Symptoms (*look for edema)
1. Polyuria?
2. Polyphagia?
3. Polydipsia?
4. Blurred vision?
5. Blood sugar?
6. Other health issues (ex. heart disease, HTN, stroke)?
Food preparation
1. What is a balanced meal to you?
2. Who goes to the market to buy the food?
3. Who prepares the meals?
4. How is the meal prepared?
5. What oil is used?
6. Do you have consistent eating patterns?
7. How much time is in-between the meals?
8. Do you snack in-between or after meals?
9. Do you feel like you get variety with meals?
10. What beverages do you drink during meals? During the day?
Family/cultural influences
1. Is there any planning for the meals during the week or on a daily basis?
2. Does your family support your dietary changes/needs?
3. What challenges do you have in staying on your diabetic diet?
Food security
1. Worried about running out of food before getting money to buy more?
2. Do you feel like you can afford fruits and vegetables for each meal?
3. Do you feel like there is enough food for every member in the household?
4. How many people are in your household?
Observation/diet
24 hour Diet Recall
a. Lunch today:
b. Breakfast this morning:
c. Dinner last night:

d. Lunch yesterday:
Assessment
1. One fist = serving of pasta, rice, vegetables
2. One handful = serving of nuts
3. One palm = serving of meat, fish, poultry
4. One thumb = serving of oil/person feeding
5. General goal: make sure at least of these – dairy products, egg yolks, fish, garlic,
lentils, beans, and vegetables (ex: cabbage, green beans, broccoli, cucumbers,
beets) – are in every meal because they will help stabilize blood sugar and make
you feel better.
6. Individual goal:
Consequences
1. Kidney failure
2. Heart disease
3. HTN
4. Blindness
5. Stroke
6. Loss of limbs
Footnotes
Exercise Questions:
1. Do you think sports are important?
2. Do you currently participate in sports?
3. What kind of sport do you do?
4. Do you have any pain when you do sport?
5. What are your barriers to doing sports?
6. Do you have anyone to exercise with?
7. Did you have to stop exercising do to your health?
8. What kind of support do you need to help you exercise?

INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE
We are interested in finding out about the kinds of physical activities that people
do as part of their everyday lives. The questions will ask you about the time you
spent being physically active in the last 7 days. Please answer each question
even if you do not consider yourself to be an active person. Please think about
the activities you do at work, as part of your house and yard work, to get from
place to place, and in your spare time for recreation, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days. Vigorous
physical activities refer to activities that take hard physical effort and make you

breathe much harder than normal. Think only about those physical activities that
you did for at least 10 minutes at a time.
1.

During the last 7 days, on how many days did you do vigorous physical
activities like heavy lifting, digging, aerobics, or fast bicycling?
_____ days per week
No vigorous physical activities

2.

Skip to question 3

How much time did you usually spend doing vigorous physical activities
on one of those days?
_____ hours per day
_____ minutes per day
Don’t know/Not sure

Think about all the moderate activities that you did in the last 7 days. Moderate
activities refer to activities that take moderate physical effort and make you
breathe somewhat harder than normal. Think only about those physical activities
that you did for at least 10 minutes at a time.
3.

During the last 7 days, on how many days did you do moderate physical
activities like carrying light loads, bicycling at a regular pace, or doubles
tennis? Do not include walking.
_____ days per week – gym class
No moderate physical activities

4.

Skip to question 5

How much time did you usually spend doing moderate physical activities
on one of those days?
_____ hours per day
_____ minutes per day
Don’t know/Not sure

Think about the time you spent walking in the last 7 days. This includes at work
and at home, walking to travel from place to place, and any other walking that
you might do solely for recreation, sport, exercise, or leisure.
5.

During the last 7 days, on how many days did you walk for at least 10
minutes at a time?
_____ days per week
No walking

6.

Skip to question 7

How much time did you usually spend walking on one of those days?
_____ hours per day
_____ minutes per day
Don’t know/Not sure

The last question is about the time you spent sitting on weekdays during the last
7 days. Include time spent at work, at home, while doing course work and during
leisure time. This may include time spent sitting at a desk, visiting friends,
reading, or sitting or lying down to watch television.
7. During the last 7 days, how much time did you spend sitting on a week
day?
_____ hours per day
_____ minutes per day
Don’t know/Not sure

This is the end of the questionnaire, thank you for participating.