quesionario diabete

The Summary of Diabetes Self- Care Activities *

The questions below ask you about your diabetes self-care activities during the past 7 days. If you were sick during the past 7 days, please think back to the last 7 days that you were not sick.

Diet

many of the last SEVEN

On how many of the last SEVEN

Smoking

smoked a cigarette—

How

DAYS did you participate in a

Have you

DAYS have you followed a

specific exercise session (such as

even one puff—during the past

healthful eating plan?

swimming, walking, biking) other

SEVEN DAYS?

than what you do around the

0. No

0 1 2 3 4 5 6 7

house or as part of your work?

1. Yes. If yes, how many

0 1 2 3 4 5 6 7

cigarettes did you smoke on an

average day?

Number of cigarettes:

On average, over the past month,

Blood Sugar Testing

last SEVEN

how many DAYS PER WEEK

On how many of the

have you followed your eating

DAYS did you test your blood

plan?

sugar?

0 1 2 3 4 5 6 7

On how many of the last SEVEN

DAYS did you eat five or more

DAYS did you test your blood

servings of fruits and vegetables?

sugar the number of times

recommended by your health care

0 1 2 3 4 5 6 7

provider?

0 1 2 3 4 5 6 7

On how many of the last SEVEN

Foot Care

DAYS did you eat high fat foods

On how many of the last SEVEN

such as red meat or full-fat dairy

DAYS did you check your feet?

products?

0 1 2 3 4 5 6 7

Exercise

many of the last SEVEN

On how many of the last SEVEN

On how

DAYS did you inspect the inside

DAYS did you participate in at

of your shoes?

least 30 minutes of physical

0 1 2 3 4 5 6 7

activity? (Total minutes of

continuous activity, including

walking).

0 1 2 3 4 5 6 7

Additional Items for the Expanded

Version of the Summary of Diabetes Self-Care Activities.

Self-Care Recommendations

2A. Which of the following has

3A. Which of the following has

1A. Which of the following has

your health care team (doctor,

nurse, dietitian or diabetes

nurse, dietitian, or diabetes

educator) advised you to do?

Please check all that apply:

_ a. Get low level exercise (such

_ a.Test your blood sugar using a

_ a. Follow a low-fat eating plan

as walking) on a daily basis.

drop of blood from your finger

_ b.Follow a complex

_ b.Exercise continuously for a

and a color chart.

carbohydrate diet

least 20 minutes at least 3 times a

_ b.Test your blood sugar using a

_ c. Reduce the number of

week.

machine to read the results.

calories you eat to lose weight	_ c. Fit exercise into your daily		_ c.Test your urine for sugar.
_ d.Eat lots of food high in	routine (for example, take stairs		_ d.Other (specify):
dietary fiber	instead of elevators, park a block		_ e. I have not been given any
_ e. Eat lots (at least 5 servings	away and walk, etc.)		advice either about testing my
per day) of fruits and vegetables	_ d.Engage in a specific amount,		blood or urine sugar level by my
_ f. Eat very few sweets (for	type, duration and level of		health care team.
example: desserts, non-diet sodas,	exercise.
candy bars)	_ e. Other (specify):
_ g.Other (specify):	_ f. I have not been given any
_ h.I have not been given any	advice about exercise by my
advice about my diet by my	health care team.
health care team.

4A. Which of the following	Diet	On how many of the last	Medications	many of the last
medications for your diabetes has	5A.	On how many of the last	6A. On how	many of the last
your doctor prescribed?	SEVEN DAYS did you space		SEVEN DAYS, did you take
Please check all that apply.	carbohydrates evenly through the		your recommended diabetes
_ a. An insulin shot 1 or 2 times a	day?		medication?
day.			0 1 2 3 4 5 6 7
_ b.An insulin shot 3 or more			OR
times a day.			7A. On how many of the last
_ c. Diabetes pills to control my			7A. On how many of the last
blood sugar level.			SEVEN DAYS did you take your
_ d.Other (specify):			recommended insulin injections?
_ e. I have not been prescribed			0 1 2 3 4 5 6 7
either insulin or pills for my
diabetes.

8A. On how many of the last	Foot Care		10A. On how many of the last
SEVEN DAYS did you take your	9A. On how many of the last		SEVEN DAYS did you soak your
recommended number of diabetes	SEVEN DAYS did you wash		feet?
pills?	your feet?		0 1 2 3 4 5 6 7
0 1 2 3 4 5 6 7	0 1 2 3 4 5 6 7

11A. On how many of the last	12A. At your last doctor’s visit,		13A. If you smoke, at your last
SEVEN DAYS did you dry	did anyone ask about your		doctor’s visit, did anyone counsel
between your toes after washing?	smoking status?		you about stopping smoking or
0 1 2 3 4 5 6 7	0 yes		offer to refer you to a stop-
0 1 2 3 4 5 6 7	0 yes		smoking program?
	1 no		0. No
			1. Yes
			2. Do not smoke.

14A. When did you last smoke a
cigarette?
_ More than two years ago, or
never smoked
_ One to two years ago
_ Four to twelve months ago
_ One to three months ago
_ Within the last month
_ Today

Scoring Instructions for the Summary of Diabetes Self-Care Activities

Scores are calculated for each of the five regimen areas assessed by the SDSCA: Diet, Exercise, Blood-Glucose Testing, Foot-Care, and Smoking Status.

Step 1:

For items 1–10, use the number of days per week on a scale of 0–7. Note that this response scale will not allow for direct comparison with the percentages provided in Table 1.

Step 2: Scoring Scales

General Diet = Mean number of days for items 1 and 2.

Specific Diet = Mean number of days for items 3, and 4, reversing item 4

(0=7, 1=6, 2=5, 3=4, 4=3, 5=2, 6=1,7=0). Given the low inter-item correlations for this scale, using the individual items is recommended.

Exercise = Mean number of days for items 5 and 6. Blood-Glucose Testing = Mean number of days for items 7 and 8. Foot-Care = Mean number of days for items 9 and 10.

Smoking Status = Item 11 (0 = nonsmoker,1 = smoker), and number of cigarettes smoked per day.

Scoring for Additional Items

Recommended regimen = Items 1A - 4A, and items 12A - 14A, no scoring required. Diet = Use total number of days for item 5A.

Medications = Use item 6A - OR - 7A AND 8A, use total number of days for item 6A, use mean number of days if both 7A and 8A are applicable.

Foot-Care = Mean number of days for items 9A - 11A, after reversing 10A and including items 9 and 10 from the brief version.

*Toobert et al. The Summary of Diabetes Self-Care Activities Measure. Diabetes Care, 23(7) July 2000: 943-950.