QUESTIONNAIRE:

Name: Age: Gender: Male/female

Weight: Height: BMI

Education: Profession:

Nutritional Status:
a) Normal b) underweight c) Overweight d) Obese
Diabetic Complications:
a) Retinopathy b) Nephropathy c) Neuropathy d) Foot ulcer e) heart disease
Other complications:
a) Hypertension b) heart disease c) Mental illness d) others
FBS level:
a) Below 100mg/dl b) 100-125mg/dl c) 126mg/dl or more
RBS level:
a) Less than 140mg/dl b) 140-199mg/dl c) above 200mg/dl
HBA1C level:
a) Less than 6.0% b) 6.0-6.4% c) 6.5% d) more than 6.5%
Glucose monitoring:
a) Daily b) Weekly c) Monthly d) Sometimes e) Never
Physical activity:
a) Daily b) 4-6 times per week c) 1-3 times per week d) No activity
e) occasionally
Screen time:
a) 30 mins b) 2-3hrs. c) 4-5hrs. d) > 5hrs. e) None
Sleep patterns:
a) Insomnia b) Shorter duration of sleep c) Normal sleep d) Excessive sleep
 Tests Values

FBS
RBS
HbA1c

Dietary pattern:
Types of food Daily 2-3 Weekly Sometimes Never
times/week

Intake of sugary foods

Intake of sugar-sweetened
beverages
Intake of snacks

Intake of cereals

Intake of fruits

Intake of vegetables

Intake of meat/fish/egg

Intake of legumes

Intake of bakery items

Intake of junk food

Number of meals/day:
1) One 2) two 3) three 4) four
Types of ghee used:
1) Hydrogenated ghee 2) Vegetable oil 3) Butter 4) Desi ghee
Type of flour:
1) Whole flour 2) Refined flour 3) Composite flour
Type of water:
1) Tap water 2) Filter water
 Respondent’s knowledge regarding nutrition and diabetes:
No. Questions Yes No
1 Do you know about the meaning of balanced diet?

2 Do you have the knowledge regarding diabetes and its

complications?
3 Do you have the knowledge regarding recommended
number of servings of fruits and vegetables for diabetics?
4 Do you have knowledge about foods that are prohibited,
and foods healthy for diabetics?
5 Do you know high sugar/carbohydrate intake leads to
high blood sugar?
6 Do you know low glycemic foods lower the high blood
sugar levels?
7 Do you know post-prandial glucose level may increase
diabetic complications?
8 Do you know poor activity, or no activity may lead to
diabetes?
9 Do you know poor activity, or no activity may lead to
being overweight?
10 Do you know high caloric intake may lead to obesity
which may cause diabetes?