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Stanford Patient Education Research meaning Stanford University School of Medicine SAMPLE QUESTIONNAIRE DIABETES You whitethorn use all or parts of the questionnaire at no charge without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 voice (650) 725-9422 facsimile machine http://patienteducation.stanford.edu self-management@stanford.edu Name: Address: City, state, zip: Telephone: infrastructure ( work ( ) ) __ Todays date: Date of birth: energize: Female Male Background 1. Ethnic origin (check White not Latino Black not Hispanic Hispanic only one): Asian or Pacific Islander Filipino American Indian/Alaskan Native Other: __________________________ 2. Please circle the highest course of instruction 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 get hitched with single only one): separated divorced widowed 4.

Please indicate downstairs which chronic condition(s) you have: Diabetes type 2 Heart unsoundness Lung unwellnessiness Diabetes type 1 Type of heart disease: Type of lung disease: High cholesterol High lineage pressure Other chronic condition Specify: 2 General Health 1. In general, would you say your health is: (Circle one) Excellent ...............................1 Very nice..............................2 Good......................................3 Fair ........................................4 measly .......................................5 Symptoms How much time during the past month... 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 scotch by your health problems?... If you want to get a wax essay, order it on our website: Ordercustompaper.com

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