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Stanford Patient Education Research Center Stanford University School of Medicine SAMPLE QUESTIONNAIRE DIABETES You may 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 fax http://patienteducation.stanford.edu self-management stanford.edu Today s date: Name: Address: City, state, zip: Telephone: home ( ) - work ( ) - Date of birth: Sex: Female Male Background only one): 1.. On days that you test your blood sugar, how many times do you test on average times 5 Physical Activities During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following (Please circle one number for each question.) less than 30 min/wk 30-60 min/wk 1-3 hrs per week more than 3 hrs/wk 1.. How confident do you feel that you know what 2 3 4 5 6 7 8 9 Very 10 confident Not at all Very confident 1 2 3 4 5 6 7 8 9 10 confident Not at all Very 6 to do when your blood sugar level goes higher or confident 1 lower than it should be 2 3 4 5 6 7 8 9 10 confident 7..

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