Self-Efficacy Survey
| NOT AT ALL CONFIDENT | TOTALLY CONFIDENT | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1. HOW CONFIDENT DO YOU FEEL THAT YOU CAN EAT YOUR MEALS EVERY 4 TO 5 HOURS EVERY DAY, INCLUDING BREAKFAST EVERY DAY? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 2. HOW CONFIDENT DO YOU FEEL THAT YOU CAN FOLLOW YOUR DIET WHEN YOU HAVE TO PREPARE OR SHARE FOOD WITH OTHER PEOPLE WHO DO NOT HAVE DIABETES? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 3. HOW CONFIDENT DO YOU FEEL THAT YOU CAN CHOOSE THE APPROPRIATE FOODS TO EAT WHEN YOU ARE HUNGRY (FOR EXAMPLE, SNACKS)? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 4. HOW CONFIDENT DO YOU FEEL THAT YOU CAN EXERCISE 15 TO 30 MINUTES, 4 TO 5 TIMES A WEEK? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 5. HOW CONFIDENT DO YOU FEEL THAT YOU CAN DO SOMETHING TO PREVENT YOUR BLOOD SUGAR LEVEL FROM DROPPING WHEN YOU EXERCISE? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 6. HOW CONFIDENT DO YOU FEEL THAT YOU KNOW WHAT TO DO WHEN YOUR BLOOD SUGAR LEVEL GOES HIGHER OR LOWER THAN IT SHOULD BE? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 7. HOW CONFIDENT DO YOU FEEL THAT YOU CAN JUDGE WHEN THE CHANGES IN YOUR ILLNESS MEAN YOU SHOULD VISIT THE DOCTOR? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 8. HOW CONFIDENT DO YOU FEEL THAT YOU CAN CONTROL YOUR DIABETES SO THAT IT DOES NOT INTERFERE WITH THE THINGS YOU WANT TO DO? | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 9. IN GENERAL, WOULD YOU SAY YOUR HEALTH IS: | Excellent | Very Good | Good | Fair | Poor | |||||||||
| 10. HOW LIKELY ARE YOU TO RECOMMEND ELIZABETH FAMILY MEDICINE TO YOUR FRIENDS AND FAMILY WHO HAVE DIABETES? | Very Likely | Somewhat Likely | Neither Likely or Unlikely | Somewhat Unlikely | Very Unlikely | |||||||||
| 11. WHAT COULD WE HAVE DONE BETTER WHEN PROVIDING DIABETES CARE? | ||||||||||
| 12. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR RACE OR THE RACE WITH WHICH YOU BEST IDENTIFY? | American Indian or Alaska Native | Asian | Black or African American | Native Hawaiian or Other Pacific Islander | Caucasian | Other | |||||||||
| 13. WHAT DO YOU CONSIDER TO BE YOUR ETHNICITY? | Hispanic or Latino | Non-Hispanic or Latino | Unknown | |||||||||
| 14. WHAT IS YOUR HIGHEST LEVEL OF EDUCATION? | Less than high school | HS graduate/GED | Some college | Associate's degree | Bachelor's degree | Master's degree | Professional degree | Doctorate degree | |||||||||