ID# _____________________

Name _____________________

Today’s Date _____________________

Diabetes Care Profile

Michigan Diabetes
Research and Training Center
DCP2.0

 1998 The University of Michigan

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 Section I - Demographics

Please answer each of the following questions by filling in the blanks with the correct answers
or by choosing the single best answer.

Note: For this survey, a Health Care Provider refers to a doctor, nurse practitioner,
or physician assistant.

Q1. Age: __ __ years old

Q2. Birth date: __ __ /__ __ /__ __

( Month / Day / Year )

Q3. Zip Code: __ __ __ __ __

Q4. Sex: 1 Male 2 Female

Q5. What year were you first told you had diabetes? (Please enter the year) __ __ __ __

Q6. What is your marital status? (check one box)

1 Never married
2 Married
3 Separated/Divorced
4 Widowed

Q7. What is your ethnic origin/race? (check one box)

1 White
2 Black
3 Hispanic
4 Native American
5 Asian or Pacific Islander
6 Arabic
7 Other _______________
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 -3-
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Q8. Where do you live most of the year? (check one box)

1 Your home, apartment or condo

2 Senior citizen apartment/condo
3 Home of a relative/friend
4 Retirement home
5 Adult foster care
6 Nursing home
7 Other _______________

Q9. How many people live with you? (check one box)

0 I live alone
1 1 person
2 2 people
3 3 people
4 4 people
5 5 or more

Q10. How much schooling have you had? (Years of formal schooling completed)
(check one box)

1 8 grades or less
2 Some high school
3 High school graduate or GED
4 Some college or technical school
5 College graduate (bachelor’s degree)
6 Graduate degree

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Q11. Which of the following best describes your current employment status? (check one box)

1 Working full-time, 35 hours or more a week

2 Working part-time, less than 35 hours a week
3 Unemployed or laid off and looking for work
4 Unemployed and not looking for work
5 Homemaker
6 In school
7 Retired
8 Disabled, not able to work
9 Something else? (Please specify): _______________________

Q12. How would you describe the insurance plan(s) you have had in the past 12 months?
(check all that apply)

1 An individual plan – the member pays for the plan premium

2 A group plan through an employer, union, etc. – the employer pays all or part
of the plan premium
3 U.S. Governmental Health Plan (e.g., Military, CHAMPUS, VA)
4 Medicaid
5 Medicare
6 I have not had an insurance plan in the past 12 months

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Q13. What type(s) of insurance plans have you had in the past 12 months?
(check all that apply)

1 Indemnity or fee-for-service plan (i.e., you choose which health care provider you
see for care without financial penalty)
2 Health Maintenance Organization (HMO) (i.e., you must have a primary care
provider who must refer you to specialty care if needed)
3 Preferred Provider Organization (PPO) (i.e., you have lower co-payments when
you see a preferred provider within the network, but you can see a provider
out-of-network for a higher co-payment)
4 Point of Service (POS) (i.e., you must have a primary care provider; you have the
option to self-refer to an in-network specialist, or you can see an out-of-network
specialist with a higher co-payment)
5 Other (please specify): _________________
6 I have not had an insurance plan in the past 12 months.

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Q14. Do you test your blood sugar? (check one box)

1 No 2 Yes Q14a. How many days a week do you test your blood
sugar?

_____ (days / week)

Q14b. On days that you test, how many times do you test
your blood sugar?

_____ (times / day)

Q14c. Do you keep a record of your blood sugar test

results? (check one box)

1 No 2 Yes 3 Only Unusual

Values

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 Section II – Health Status

Q1. In general, would you say your health is: (check one box)

1 2 3 4 5

Excellent Very Good Good Fair Poor

Q2. These questions ask about how you feel and how things have been with you during the
past 4 weeks. For each question, please give the one answer that comes closest to the
way you have been feeling.

How much of the time during the past 4 weeks: (circle one answer for each line)

All Most A Good Some A Little None

of the of the Bit of the of the of the of the
Time Time Time Time Time Time
A. Have you felt calm and 1 2 3 4 5 6
peaceful?
B. Did you have a lot of energy? 1 2 3 4 5 6

C. Have you felt downhearted 1 2 3 4 5 6

and blue?

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 Section III – Education / Advice Received

Q1. Has your health care provider or nurse ever told you to take special care of your feet?
(check one box)

1 No 2 Yes 3 Not Sure

Q2. Has your health care provider or nurse ever told you to follow an exercise program?
(check one box)

1 No 2 Yes 3 Not Sure

Q3. Has your health care provider or nurse ever told you to follow a meal plan or diet?
(check one box)

1 No 2 Yes 3 Not Sure

Q4. Have you ever received diabetes education? (for example: attended a series of classes or
series of meetings with a diabetes educator) (check one box)

1 No 2 Yes 3 Not Sure

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 Section IV - Understanding

Q1. How do you rate your understanding Poor Good Excellent

of: (circle one answer for each line)
a) overall diabetes care 1 2 3 4 5
b) coping with stress 1 2 3 4 5
c) diet for blood sugar control 1 2 3 4 5
d) the role of exercise in diabetes care 1 2 3 4 5
e) medications you are taking 1 2 3 4 5
f) how to use the results of blood 1 2 3 4 5
sugar monitoring
g) how diet, exercise, and medicines 1 2 3 4 5
affect blood sugar levels
h) prevention and treatment of high 1 2 3 4 5
blood sugar
i) prevention and treatment of low 1 2 3 4 5
blood sugar
j) prevention of long-term 1 2 3 4 5
complications of diabetes
k) foot care 1 2 3 4 5
l) benefits of improving blood sugar 1 2 3 4 5
control
m) pregnancy and diabetes 1 2 3 4 5

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 Section V – Support
Q1. I want a lot of help and support from my family or friends in:
(circle one answer for each line)

Does
Strongly Somewhat Somewhat Strongly Not
Disagree Disagree Neutral Agree Agree Apply
a) following my meal 1 2 3 4 5 N/A
plan.
b) taking my medicine. 1 2 3 4 5 N/A
c) taking care of my feet. 1 2 3 4 5 N/A
d) getting enough 1 2 3 4 5 N/A
physical activity.
e) testing my sugar. 1 2 3 4 5 N/A
f) handling my feelings 1 2 3 4 5 N/A
about diabetes.

Q2. My family or friends help and support me a lot to:

(circle one answer for each line)

Does
Strongly Somewhat Somewhat Strongly Not
Disagree Disagree Neutral Agree Agree Apply
a) follow my meal plan. 1 2 3 4 5 N/A
b) take my medicine. 1 2 3 4 5 N/A
c) take care of my feet. 1 2 3 4 5 N/A
d) get enough physical 1 2 3 4 5 N/A
activity.
e) test my sugar. 1 2 3 4 5 N/A

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f) handle my feelings 1 2 3 4 5 N/A
about diabetes.

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Q3. My family or friends: (circle one answer for each line)

Strongly Somewhat Somewhat Strongly

Disagree Disagree Neutral Agree Agree
a) accept me and my diabetes. 1 2 3 4 5
b) feel uncomfortable about me 1 2 3 4 5
because of my diabetes.
c) encourage or reassure me 1 2 3 4 5
about my diabetes.
d) discourage or upset me about 1 2 3 4 5
my diabetes.
e) listen to me when I want to 1 2 3 4 5
talk about my diabetes.
f) nag me about diabetes. 1 2 3 4 5

Q4. Who helps you the most in caring for your diabetes? (check only one box)

1 Spouse
2 Other family members
3 Friends
4 Paid helper
5 Doctor
6 Nurse
7 Case manager
8 Other health care professional
9 No one

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 DCP Appendices

Section VI - Control Problems Scale

For the following questions, please check the appropriate response.

Q1. How many times in the last month have you had a low blood sugar (glucose) reaction
with symptoms such as sweating, weakness, anxiety, trembling, hunger or headache?

1 0 times
2 1-3 times
3 4-6 times
4 7-12 times
5 More than 12 times
6 Don’t know

Q2. How many times in the last year have you had severe low blood sugar reactions such as
passing out or needing help to treat the reaction?

1 0 times
2 1-3 times
3 4-6 times
4 7-12 times
5 More than 12 times
6 Don’t know

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Q3. How many days in the last month have you had high blood sugar with symptoms such
as thirst, dry mouth and skin, increased sugar in the urine, less appetite, nausea, or
fatigue?

1 0 days
2 1-3 days
3 4-6 days
4 7-12 days
5 More than 12 days
6 Don’t know

Q4. How many days in the last month have you had ketones in your urine?

1 0 days
2 1-3 days
3 4-6 days
4 7-12 days
5 More than 12 days
6 Don’t test

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Q5. During the past year, how often did your
blood sugar become too high because: Don't
(circle one answer for each line) Never Sometimes Often Know

a) you were sick or had an infection? 1 2 3 4 5 DK

b) you were upset or angry? 1 2 3 4 5 DK
c) you took the wrong amount of 1 2 3 4 5 DK
medicine?
d) you ate the wrong types of food? 1 2 3 4 5 DK
e) you ate too much food? 1 2 3 4 5 DK
f) you had less physical activity than 1 2 3 4 5 DK
usual?
g) you were feeling stressed? 1 2 3 4 5 DK

Q6. During the past year, how often did your

blood sugar become too low because: Don't
(circle one answer for each line) Never Sometimes Often Know

a) you were sick or had an infection? 1 2 3 4 5 DK

b) you were upset or angry? 1 2 3 4 5 DK
c) you took the wrong amount of 1 2 3 4 5 DK
medicine?
d) you ate the wrong types of food? 1 2 3 4 5 DK
e) you ate too little food? 1 2 3 4 5 DK
f) you had more physical activity than 1 2 3 4 5 DK
usual?
g) you waited too long to eat or skipped 1 2 3 4 5 DK
a meal?
h) you were feeling stressed? 1 2 3 4 5 DK
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 Section VII - Social and Personal Factors Scale

For the following questions, please circle the appropriate response.

Don't
Never Sometimes Often Know
Q1. How often has your diabetes kept you
from doing your normal daily activities
1 2 3 4 5 DK
during the past year (e.g., couldn't: go
to work, work around the house, go to
school, visit friends)?

Q2. My diabetes and its treatment keep

me from: (circle one answer for Strongly Disagree Neutral Agree Strongly
each line) Disagree Agree

a) having enough money. 1 2 3 4 5

b) meeting school, work, 1 2 3 4 5
household, and other
responsibilities.
c) going out or traveling as much 1 2 3 4 5
as I want.
d) being as active as I want. 1 2 3 4 5
e) eating foods that I like. 1 2 3 4 5
f) eating as much as I want. 1 2 3 4 5
g) having good relationships with 1 2 3 4 5
people.
h) keeping a schedule I like (e.g., 1 2 3 4 5
eating or sleeping late).
i) spending time with my friends. 1 2 3 4 5
j) having enough time alone. 1 2 3 4 5

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 Strongly Strongly
Disagree Disagree Neutral Agree Agree

Q3. Paying for my diabetes 1 2 3 4 5

treatment and supplies is a
problem.

Strongly Strongly
Disagree Disagree Neutral Agree Agree

Q4. Having diabetes makes my life 1 2 3 4 5

difficult.

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 Section VIII - Attitudes Toward Diabetes Scales

(Positive Attitude, Negative Attitude, Care Ability,

Importance of Care, and Self-Care Adherence)

For the following questions, please circle the appropriate response.

(circle one answer for each line)

Strongly Strongly
Disagree Disagree Neutral Agree Agree

Q1. I am afraid of my 1 2 3 4 5
diabetes.
Q2. I find it hard to believe 1 2 3 4 5
that I really have diabetes.
Q3. I feel unhappy and 1 2 3 4 5
depressed because of my
diabetes.
Q4. I feel satisfied with my 1 2 3 4 5
life.
Q5. I feel I'm not as good as 1 2 3 4 5
others because of my
diabetes.
Q6. I can do just about 1 2 3 4 5
anything I set out to do.
Q7. I find it hard to do all the 1 2 3 4 5
things I have to do for my
diabetes.
Q8. Diabetes doesn't affect my 1 2 3 4 5
life at all.
Q9. I am pretty well off, all 1 2 3 4 5
things considered.
Q10. Things are going very 1 2 3 4 5
well for me right now.
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Q11. I am able to: (circle one answer Strongly Strongly
for each line) Disagree Disagree Neutral Agree Agree
a) keep my blood sugar in 1 2 3 4 5
good control.
b) keep my weight under 1 2 3 4 5
control.
c) do the things I need to do 1 2 3 4 5
for my diabetes (diet,
medicine, exercise, etc.).
d) handle my feelings (fear, 1 2 3 4 5
worry, anger) about my
diabetes.

Q12. I think it is important for me Strongly Strongly

to: (circle one answer for each Disagree Disagree Neutral Agree Agree
line)
a) keep my blood sugar in 1 2 3 4 5
good control.
b) keep my weight under 1 2 3 4 5
control.
c) do the things I need to do 1 2 3 4 5
for my diabetes (diet,
medicine, exercise, etc.).
d) handle my feelings (fear, 1 2 3 4 5
worry, anger) about my
diabetes.

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 Don't
Never Sometimes Always Know

Q13. I keep my blood sugar in 1 2 3 4 5 DK

good control.

Never Sometimes Always

Q14. I keep my weight under control. 1 2 3 4 5
Q15. I do the things I need to do for my 1 2 3 4 5
diabetes (diet, medicine, exercise,
etc.).
Q16. I feel dissatisfied with life because of 1 2 3 4 5
my diabetes.
Q17. I handle the feelings (fear, worry, 1 2 3 4 5
anger) about my diabetes fairly well.

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 Section IX - Diet Adherence Scale

Q1. Has any health care provider or nurse 1 No 2 Yes 3 Not sure
told you to follow a meal plan or diet?

Never Sometimes Always

Q2. How often do you follow a meal plan 1 2 3 4 5

or diet?

Q3. Have you been told to follow a schedule for 1 No 2 Yes

your meals and snacks?

Q4. Have you been told to weigh or measure 1 No 2 Yes

your food?

Q5. Have you been told to use exchange lists or 1 No 2 Yes

food group lists to plan your meals?

Never Sometimes Always

Q6. How often do you follow the schedule 1 2 3 4 5
for your meals and snacks?
Q7. How often do you weigh or measure 1 2 3 4 5
your food?
Q8. How often do you (or the person who 1 2 3 4 5
cooks your food) use the exchange
lists or food group lists to plan your
meals?

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 Section X - Long-Term Care Benefits Scale

For the following questions, please circle the appropriate response.

(circle one answer for each line)

Q1. Taking the best possible care of Strongly Strongly

diabetes will delay or prevent: Disagree Disagree Neutral Agree Agree
a) eye problems 1 2 3 4 5
b) kidney problems 1 2 3 4 5
c) foot problems 1 2 3 4 5
d) hardening of the arteries 1 2 3 4 5
e) heart disease 1 2 3 4 5

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 Section XI - Exercise Barriers Scale

For the following questions, please circle the appropriate response.

(circle one answer for each line)

Q1. How often do you have trouble getting

enough exercise because: Rarely Sometimes Often
a) it takes too much effort? 1 2 3 4 5
b) you don't believe it is useful? 1 2 3 4 5
c) you don't like to do it? 1 2 3 4 5
d) you have a health problem? 1 2 3 4 5
e) it makes your diabetes more difficult 1 2 3 4 5
to control?

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 Section XII - Monitoring Barriers and Understanding Management Practice Scales

Q1. How many days a week have you been told to test:

a) urine sugar? _____ (days per week) 9 Not told to test

b) blood sugar? _____ (days per week) 9 Not told to test

If you do not test for sugar, skip Question No. 2.

For the following questions, please circle the appropriate response.

(circle one answer for each line)

Q2. When you don't test for sugar as often

as you have been told, how often is it
because: Rarely Sometimes Often
a) you forgot? 1 2 3 4 5
b) you don't believe it is useful? 1 2 3 4 5
c) the time or place wasn't right? 1 2 3 4 5
d) you don't like to do it? 1 2 3 4 5
e) you ran out of test materials? 1 2 3 4 5
f) it costs too much? 1 2 3 4 5
g) it's too much trouble? 1 2 3 4 5
h) it's hard to read the test results? 1 2 3 4 5
i) you can't do it by yourself? 1 2 3 4 5
j) your levels don’t change very 1 2 3 4 5
often?
k) it hurts to prick your finger? 1 2 3 4 5

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Q3. Have you ever received diabetes education? 1 No 2 Yes

If No, skip Question No. 4

For the following questions, please circle the appropriate response.

(circle one answer for each line)

Q4. How do you rate your understanding of:

Poor Good Excellent
a) diet and blood sugar control 1 2 3 4 5
b) weight management 1 2 3 4 5
c) exercise 1 2 3 4 5
d) use of insulin/pills 1 2 3 4 5
e) sugar testing 1 2 3 4 5
f) foot care 1 2 3 4 5
g) complications of diabetes 1 2 3 4 5
h) eye care 1 2 3 4 5
i) combining diabetes medication 1 2 3 4 5
with other medications
j) alcohol use and diabetes 1 2 3 4 5

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 Addition to Section I (Demographics) - Income Question

Q15. Which of the categories best describes your total annual combined household income
from all sources? (check one box)

01 Less than $5,000

02 $5,000 to $9,999

03 $10,000 to $14,999

04 $15,000 to $19,999

05 $20,000 to $29,999

06 $30,000 to $39,999

07 $40,000 to $49,999

08 $50,000 to $59,999

09 $60,000 to $69,999

10 $70,000 and over

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 Addition to Section I (Demographics) - Occupation Question (from NHANES III)

Q15/Q16. During the past 2 weeks, did you work at any time at a job or business,
not counting work around the house?

1 No 2 Yes

Q15a/Q16a. What kind of work were you doing?

(For example: electrical engineer, stock clerk, typist, farmer.)

01 Executive, administrators, and 21 Miscellaneous food preparation

managers and service occupations
02 Management related occupations 22 Health service occupations
03 Engineers and scientists 23 Cleaning and building service
occupations
04 Health diagnosing, assessment, and 24 Personal service occupations
treating occupations
05 Teachers 25 Farm operators, managers, and
supervisors
06 Writers, artists, entertainers, and 26 Farm and nursery workers
athletes
07 Other professional specialty occupations 27 Related agricultural, forestry,
and fishing occupations
08 Technicians and related support 28 Vehicle and mobile equipment
occupations mechanics and repairers
09 Supervisors and proprietors, sales 29 Other mechanics and repairers
occupations
10 Sales representatives, finance, business, 30 Construction trades
and commodities except retail
11 Sales workers, retail and personal 31 Extractive and precision production
business occupations
12 Secretaries, stenographers, and typists 32 Textile, apparel, and furnishings
machine operators
13 Information clerks 33 Machine operators, assorted
materials
14 Records processing occupations 34 Fabricators, assemblers, inspectors,
and samplers
15 Material recording, scheduling, 35 Motor vehicle operators
and distributing clerks
16 Miscellaneous administrative 36 Other transportation and
support occupations material moving occupations
17 Private household occupations 37 Construction laborers
18 Protective service occupations 38 Laborers, except construction
19 Waiters and waitresses 39 Freight, stock, and material movers
20 Cooks 40 Other handlers, equipment
cleaners, and handlers
41 Don’t Know

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 Replace Section II (Health Status) with SF-12

Q1. In general, would you say your health is: (check one box)

1 2 3 4 5

Excellent Very Good Good Fair Poor

The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much? (check one box for each line)

Yes, Limited a Yes, Limited a No, Not

Lot Little limited at all
Q2. Moderate activities, such as moving a
table, pushing a vacuum cleaner, 1 2 3
bowling, or playing golf

Q3. Climbing several flights of stairs 1 2 3

During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health? (check one box for each line)

Yes No
Q4. Accomplished less than you would like 1 2

Q5. Were limited in the kind of work or other 1 2

activities

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During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)? (check one box for each line)
Yes No

Q6. Accomplished less than you would like 1 2

Q7. Didn’t do work or other activities as carefully as usual 1 2

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Q8. During the past 4 weeks, how much did pain interfere with your normal work (including
both work outside the home and housework)? (check one box)

1 2 3 4 5

Not at all A little bit Moderately Quite a bit Extremely

These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question please give the one answer that comes closest to the
way you have been feeling.

How much of the time during the past 4 weeks: (circle one answer for each line)

All Most A Good Some A Little None

of the of the Bit of the of the of the of the
Time Time Time Time Time Time
Q9. Have you felt calm and 1 2 3 4 5 6
peaceful?
Q10. Did you have a lot of energy? 1 2 3 4 5 6

Q11. Have you felt downhearted 1 2 3 4 5 6

and blue?

Q12. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
(check one box)

1 2 3 4 5
All of the Most of the Some of the A little of None of the
time time time the time time

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 Replace Section II (Health Status) with SF-36

Q1. In general, would you say your health is: (check one box)

1 2 3 4 5
Excellent Very Good Good Fair Poor

Q2. Compared to one year ago, how would you rate your health in general now?
(check one box)

1 Much better now than 1 year ago

2 Somewhat better now than 1 year ago
3 About the same
4 Somewhat worse now than 1 year ago
5 Much worse now than 1 year ago

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Q3. The following questions are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
(circle one answer on each line)

Yes, Yes, No, Not

Limited Limited Limited
A Lot A Little At All
A. Vigorous activities, such as running, lifting heavy 1 2 3
objects, participating in strenuous sports?
B. Moderate activities, such as moving a table, 1 2 3
pushing a vacuum cleaner, bowling, or playing
golf?
C. Lifting or carrying groceries? 1 2 3

D. Climbing several flights of stairs? 1 2 3

E. Climbing one flight of stairs? 1 2 3

F. Bending, kneeling, or stooping? 1 2 3

G. Walking more than a mile? 1 2 3

H. Walking several blocks? 1 2 3

I. Walking one block? 1 2 3

J. Bathing or dressing yourself? 1 2 3

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Q4. During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
(circle one answer on each line)

Yes No
A. Cut down the amount of time you spent on work or other 1 2
activities
B. Accomplished less than you would like 1 2

C. Were limited in the kind of work or other activities 1 2

D. Had difficulty performing the work or other 1 2

activities (for example, it took extra effort)

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Q5. During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling
depressed or anxious)? (circle one answer on each line)

Yes No
A. Cut down the amount of time you spent on 1 2
work or other activities
B. Accomplished less than you would like 1 2

C. Didn’t do work or other activities as carefully 1 2

as usual

Q6. During the past 4 weeks, to what extent has your physical health or emotional problems
interfered with your normal social activities with family, friends, neighbors, or groups?
(check one box)

1 2 3 4 5

Not at all Slightly Moderately Quite a bit Extremely

Q7. How much bodily pain have you had during the past 4 weeks? (check one box)

1 2 3 4 5 6

None Very Mild Mild Moderate Severe Very Severe

Q8. During the past 4 weeks, how much did pain interfere with your normal work (including
both work outside the home and housework)? (check one box)

1 2 3 4 5

Not at all A little bit Moderately Quite a bit Extremely

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Q9. These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question please give the one answer that comes closest to the
way you have been feeling.

How much of the time during the past 4 weeks: (circle one answer on each line)

All Most A Good Some A Little None

of the of the Bit of of the of the of the
Time Time the Time Time Time
Time
A. Did you feel full of pep? 1 2 3 4 5 6

B. Have you been a very 1 2 3 4 5 6

nervous person?
C. Have you felt so down in 1 2 3 4 5 6
the dumps that nothing
could cheer you up?
D. Have you felt calm and 1 2 3 4 5 6
peaceful?
E. Did you have a lot of 1 2 3 4 5 6
energy?
F. Have you felt 1 2 3 4 5 6
downhearted and blue?
G. Did you feel worn out? 1 2 3 4 5 6

H. Have you been a happy 1 2 3 4 5 6

person?
I. Did you feel tired? 1 2 3 4 5 6

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Q10. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
(check one box)

1 All of the time

2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time

Q11. Please choose the answer that best describes how true or false each of the following
statements is for you. (circle one answer on each line)

Definitely Mostly Not Mostly Definitely

True True Sure False False
A. I seem to get sick a little easier 1 2 3 4 5
than other people.
B. I am as healthy as anybody I 1 2 3 4 5
know.
C. I expect my health to get worse. 1 2 3 4 5

D. My health is excellent. 1 2 3 4 5

Q12a. Which are you? (check one box)

1 Male

2 Female

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Q12b. How old were you on your last birthday? (check one box)
1 Less than 35

2 35-44
3 45-54
4 55-64
5 65-74
6 75-84
7 85 and older

Q13. Have you ever filled out this form before? (check one box)
1 Yes

2 No
3 Don’t remember

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-
DCP Questions Needed for Cost Effectiveness Analysis

Essential:
1. Employment Question (Section I - Q11)
2. Age, Date of DM Diagnosis, and Race Questions (Section I - Q1, Q5, Q7)

Often Needed:
1. Occupation Question (appendix)
2. Health Insurance Questions (Section I - Q12 and Q13)
3. Income Question (appendix)

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 DCP Summary

Core Questions:
Section I – Demographics (Q1 – Q14)
Section II – Health Status (Q1 – Q2)
Section III – Education / Advice Received (Q1 – Q4)
Section IV – Understanding (Q1)
Section V – Support (Q1 – Q4)

Appendices:
Section VI – Control Problems Scale
Section VII – Social and Personal Factors Scale
Section VIII – Attitudes Toward Diabetes Scales
Section IX – Diet Adherence Scales
Section X – Long-term care benefits Scale
Section XI – Exercise Barriers Scale
Section XII – Monitoring Barriers and Understanding Management Practice Subscales
(add understanding subscale to the end of Section IV)

Addition to Section I (Demographics) – Income Question (Q15)

Addition to Section I (Demographics) – Occupation Question (Q15 or Q16)

Replace Section II (Health Status) with SF-12

Replace Section II (Health Status) with SF-36

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