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Your Health, Your Voice
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This short survey will only take a few minutes and will help us know more about how you are doing. Please answer these questions honestly.
How would you rate your health on a scale of 1 to 10?
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(1 = My health is bad;10 = My health is great.)
1
2
3
4
5
6
7
8
9
10
Questions #2 through #5 are statements that people sometimes make when they talk about their health. Please let us know how much you agree or disagree with each one.
“I am responsible for managing my health condition.”
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Strongly agree
Agree
Not sure
Disagree
Strongly disagree
“The best thing I can do for my health is take care of myself and make healthy choices every day.”
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Strongly agree
Agree
Not sure
Disagree
Strongly disagree
“I know what I need to do to manage my medical condition(s), like diabetes.”
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Strongly agree
Agree
Not sure
Disagree
Strongly disagree
“I know when I need to call my doctor for help.”
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Strongly agree
Agree
Not sure
Disagree
Strongly disagree
Hidden
GP4_Score
Do you check your blood pressure the way your health care provider told you to?
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Yes
No
Do you know your blood pressure?
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Yes
No
What was your blood pressure the last time you took it?
Systolic (first number):
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Diastolic (second number):
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Have you had an A1c test?
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Yes
No
Do you know your A1c?
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Yes
No
What was your A1c the last time it was measured?
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When was your last eye exam?
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MM slash DD slash YYYY
Have you been going to your doctor’s appointments?
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Yes
Most of the time
Sometimes
No
Please let us know why:
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It’s hard to get to the doctor.
I forget.
I cannot get off from work.
I have problems making appointments.
Other
You chose "Other", please specify:
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How often do you exercise?
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Daily
4-5 days a week
1-3 days a week
Less than once a week
Never
Do you take your diabetic medication the way your doctor prescribed?
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Yes
Sometimes
No
Not sure
Please let us know why:
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(Select all that apply.)
I can't afford the prescription.
I don't like the side effects.
I forget.
I ran out.
I am having trouble contacting my health care provider.
It will not make a difference in my health.
I feel fine, so I don’t need to take my medication.
Other
You chose "Other", please specify:
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Which of the following do you eat/drink multiple times during the day?
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(Select all that apply.)
Sugary snacks
Sugary drinks, fruit juice, and/or non-diet soda
Diet soda
Coffee/tea
Alcohol
None of these
How often do you smoke/vape?
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Never
Not currently, but have a history of smoking/vaping
Frequently (multiple times per week)
Daily
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