Questionnaire on Health Maintenance Activities of Type 2 Diabetic Individuals Part I.

Personal Information Instruction: Please put a check on the appropriate spaces provided corresponding to your answer. Gender: ___ Male Age: ___40 and below ___ 41-45 ___ 46-50 ___ 51-55 ___ 56-60 ___ 61-65 ___ 66-70 ___ 70 and older ___ Female

Marital Status: ___ Married ____ Divorced ____ Widowed

___ Unmarried

____ Separated

____ Single

Educational Attainment: ___ Elementary level ___ Elementary Graduate ___ High School Level ___ High School Graduate ___ College Level ___ College Graduate ___ Vocational ____ Others, Please Specify:_______

Monthly Income: ___ 5,000-9,000 ___ 10,000- 14,000 ____15,000-19,000 ____ 20,000 and above

Who is supporting you? _________________

Part II. Health Maintenance Activities Direction: Please encircle the appropriate letter of your choice that corresponds to what you are actually doing regarding the statement. Diet 1. I eat the prescribed diet for a diabetic individual (low salt, low fat, low sugar). a. Never Always 2. I am able to consume adequate amounts of food 3 meals a day. a. Never Always 3. I refrain from skipping meals. a. Never Always 4. I avoid excessive eating of foods high in fats ( eg. Humba, Lechon, etc.) b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

a. Never Always

b. Rarely

c. Sometimes

d. Most of the time

e.

5. I Eat very few sweets (for example: desserts, non-diet sodas, candy bars) a. Never Always 6. I avoid excessive eating of foods high in salt (eg. bulad, ginamos, etc.) a. Never Always 7. I quantify my food in the right amount before I eat. a. Never Always 8. I Resist overeating or missing meals when I am anxious or nervous. a. Never Always 9. I Resist overeating or missing meals when depressed or down. a. Never Always 10. I Eat meals at the same time every day. a. Never b. Rarely c. Sometimes d. Most of the time Always 11. I Stay on my meal plan when people around me don't know that I have diabetes. a. Never b. Rarely c. Sometimes d. Most of the time e. Always 12. I Exchange one food for another in the same food group. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

e.

a. Never Always

b. Rarely

c. Sometimes

d. Most of the time

e.

13. I Avoid overeating or missing meals when angry or upset. a. Never b. Rarely c. Sometimes d. Most of the time Always 14. I Avoid overeating or missing meals when happy or relaxed. a. Never b. Rarely c. Sometimes d. Most of the time Always

e.

e.

15. I follow my diabetic diet when I eat outside (such as in fastfoods, fiesta, baptismal, wedding, birthdays and other gatherings). a. Never Always 16. I avoid eating in fastfood chains. a. Never Always 17. I Use sugar free products or foods. a. Never Always 18. I refrain from eating junk foods. a. Never Always 19. I eat five or more servings of fruits and Vegetables. a. Never Always Exercise 1. I perform light to moderate exercise at least 20 30 min everyday. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

a. Never Always

b. Rarely

c. Sometimes

d. Most of the time

e.

2. I participate in a specific exercise session (swimming, brisk walking, etc.) other than what I do around the house or as part of my work. a. Never Always 3. I exercise to help reduce my weight or achieve my ideal weight. a. Never Always 4. I have enough time to exercise. a. Never Always 5. I am eager and motivated to exercise. a. Never Always 6. I Prevent low blood sugar reactions when exercising. a. Never Always 7.I Fit exercise into my daily routine (for example, take stairs instead of elevators, park a block away and walk, etc.) a. Never Always 8. I Exercise when I don't feel like it. a. Never b. Rarely c. Sometimes Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

d. Most of the time

e.

9. I remain active even when there are a lot of demands at home or at work. a. Never b. Rarely c. Sometimes d. Most of the time e. Always 10. I remain active even when feeling tired. a. Never b. Rarely c. Sometimes d. Most of the time Always

e.

Medication Adherence 1. I take my medication before meals at the right dose as prescribed. a. Never Always 2. I take my medication before meals or at the right time as prescribed. a. Never Always 3. I dont forget to take my medication at the prescribed time. a. Never Always 4. I bring my medication wherever I go. a. Never Always 5. I have enough supply of my medications. a. Never Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

6. I take my insulin medications when away from home. a. Never Always 7. I Figure out how much insulin to take when there is a change in my usual day. a. Never Always 8. I take correct amount of insulin when having a cold or the flu. a. Never Always 9. I do not stop taking my medications without consulting my physician. a. Never Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

Blood Glucose Monitoring 1. I monitor my blood glucose level. a. Never Always 2. I keep records of the results of my blood glucose level. a. Never Always 3. I am able to check my blood glucose level on my own. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

a. Never Always

b. Rarely

c. Sometimes

d. Most of the time

e.

4. I visit my health care provider at scheduled time to help me monitor my blood glucose level. a. Never Always 5. I test my blood sugar at least once per week or as recommended by my physician. a. Never Always 6. I Test my blood sugar even when away from home. a. Never Always 7. I am able to recognize when blood sugar is high or low. a. Never Always Foot Care 1. I check my feet everyday for any lesions,cracked or dry skin or wounds. a. Never Always 2. I Apply proper lotion to my feet. a. Never Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

3. I avoid applying lotion in between my toes. a. Never Always 4. I wear footwear that fits well to me. a. Never Always 5. I use protective footwear when I go outdoors. a. Never Always 6. I avoid being bare foot. a. Never Always 7. I inspect the inside of my shoes before wearing it. a. Never Always 8. I avoid shoes that expose my toes or heels. a. Never Always 9. I avoid too much exposure to cold or heat. a. Never Always 10. I Cut my toenails straight across. a. Never Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

11. I avoid cutting my nails into the corners of my toes a. Never Always b. Rarely c. Sometimes d. Most of the time e.

Lifestyle-Alcohol intake and Smoking habits 1. I smoke cigarettes/tobacco. a. Never Always 2. I am exposed to cigarette smoking at home or at work. a. Never Always 3. I stay away from places where people are smoking. a. Never Always 4. I avoid cigarette smoking since I was diagnosed with Diabetes Mellitus. a. Never Always 5. I drink alcoholic beverages. a. Never Always 6. I drink alcoholic beverages moderately (no more than 1 drink per day). b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.

a. Never Always

b. Rarely

c. Sometimes

d. Most of the time

e.

7. I avoid drinking alcoholic beverages since I was diagnosed with Diabetes Mellitus. a. Never Always 8. I avoid drinking excessive alcoholic beverages. a. Never Always b. Rarely c. Sometimes d. Most of the time e. b. Rarely c. Sometimes d. Most of the time e.