Form MMH-4 "Diabetes Self-management Program "take Control of Your Health" Post-workshop Participant Survey" - New Jersey

What Is Form MMH-4?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MMH-4 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form MMH-4 "Diabetes Self-management Program "take Control of Your Health" Post-workshop Participant Survey" - New Jersey

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New Jersey Department of Health
Office of Minority and Multicultural Health
DIABETES SELF-MANAGEMENT PROGRAM
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
ID Number:
Date:
Zip Code:
Monitoring Sugar Level
1.
Do you have a machine to test your blood sugar (glucose) level at home?
Yes
No
If yes, how many days in the last week did you test your blood sugar
2.
level? (If you were sick in the last week, think of the most recent 7 days
________ days
when you were NOT sick).
3.
Do you know what the results mean?
Yes
No
4.
Have you had a Hemoglobin A1c test in the past month?
Yes
No
I. In general, would you say your health is: (check only one)
Excellent
Very Good
Good
Fair
Poor
II. In the PAST WEEK, did you ever have any of the following symptoms: (Check only one)
1.
Increased thirst?
Yes
No
Don’t Know
2.
Dry mouth?
Yes
No
Don’t Know
3.
Decreased need for food?
Yes
No
Don’t Know
4.
Sickness in stomach or vomiting?
Yes
No
Don’t Know
5.
Belly pain?
Yes
No
Don’t Know
6.
Do you have to get up to urinate 3 or more times a night?
Yes
No
Don’t Know
7.
High blood sugar readings (300 mg or higher)?
Yes
No
Don’t Know
8.
Morning headaches?
Yes
No
Don’t Know
9.
Bad dreams?
Yes
No
Don’t Know
10.
Night sweats?
Yes
No
Don’t Know
11.
Lightheadedness or dizziness?
Yes
No
Don’t Know
12.
Shakiness or weakness?
Yes
No
Don’t Know
13.
Severe hunger?
Yes
No
Don’t Know
14.
Times when you fainted or passed out, even for a short time?
Yes
No
Don’t Know
MMH-4
MAR 16
Page 1
New Jersey Department of Health
Office of Minority and Multicultural Health
DIABETES SELF-MANAGEMENT PROGRAM
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
ID Number:
Date:
Zip Code:
Monitoring Sugar Level
1.
Do you have a machine to test your blood sugar (glucose) level at home?
Yes
No
If yes, how many days in the last week did you test your blood sugar
2.
level? (If you were sick in the last week, think of the most recent 7 days
________ days
when you were NOT sick).
3.
Do you know what the results mean?
Yes
No
4.
Have you had a Hemoglobin A1c test in the past month?
Yes
No
I. In general, would you say your health is: (check only one)
Excellent
Very Good
Good
Fair
Poor
II. In the PAST WEEK, did you ever have any of the following symptoms: (Check only one)
1.
Increased thirst?
Yes
No
Don’t Know
2.
Dry mouth?
Yes
No
Don’t Know
3.
Decreased need for food?
Yes
No
Don’t Know
4.
Sickness in stomach or vomiting?
Yes
No
Don’t Know
5.
Belly pain?
Yes
No
Don’t Know
6.
Do you have to get up to urinate 3 or more times a night?
Yes
No
Don’t Know
7.
High blood sugar readings (300 mg or higher)?
Yes
No
Don’t Know
8.
Morning headaches?
Yes
No
Don’t Know
9.
Bad dreams?
Yes
No
Don’t Know
10.
Night sweats?
Yes
No
Don’t Know
11.
Lightheadedness or dizziness?
Yes
No
Don’t Know
12.
Shakiness or weakness?
Yes
No
Don’t Know
13.
Severe hunger?
Yes
No
Don’t Know
14.
Times when you fainted or passed out, even for a short time?
Yes
No
Don’t Know
MMH-4
MAR 16
Page 1
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
(Continued)
(Circle one)
III. Daily Activities
Almost
Not at all
Slightly
Moderately
Quite a bit
totally
During the past 2 weeks, how much has
0
1
2
3
4
1.
your sickness stopped you from being with
family, friends, neighbors or groups?
During the past 2 weeks, how much has
your sickness stopped you from doing things
2.
0
1
2
3
4
you enjoy like reading, playing sports or other
fun things?
During the past 2 weeks, how much has
your sickness stopped you from doing
0
1
2
3
4
3.
everyday work around your house (e.g.
cleaning, cooking etc.)?
During the past 2 weeks, how much has
4.
your sickness stopped you from doing other
0
1
2
3
4
things that you need to do such as shopping?
IV. Controlling My Sickness
For each of the following questions, please
Strongly
Strongly
Disagree
Neutral
Agree
circle one number for each question that tells
disagree
agree
how you feel about doing things easily at this
time:
I eat meals every 4 to 5 hours every day,
1.
1
2
3
4
5
including breakfast every day.
I follow my diet and know what to eat when I
1
2
3
4
5
2.
am hungry.
I exercise 15 to 30 minutes, 4 to 5 times a
3.
1
2
3
4
5
week.
I know how to stop my blood sugar level from
1
2
3
4
5
4.
falling when I exercise.
I know what to do when my blood sugar level
5.
1
2
3
4
5
goes higher or lower than it should be
Feeling tired from being sick does not stop
1
2
3
4
5
6.
me from doing things that I want to do.
Fear or worry from being sick does not stop
7.
1
2
3
4
5
me from doing things I want to do.
I know my medications and take them
1
2
3
4
5
8.
everyday.
I go for all my doctor appointments needed
9.
1
2
3
4
5
for my treatment.
I know when the changes in my sickness
1
2
3
4
5
10.
mean I should go to my doctor.
MMH-4
MAR 16
Page 2
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
(Continued)
V. During the past week, how much total time
Less than
30 - 60
1 – 3
More than
did you spend on the following:
None
30 min/wk
min/wk
hrs/wk
3 hrs/wk
(check only one)
1
2
3
4
5
1.
Stretching or using weights
1
2
3
4
5
2.
Walking for exercise
3.
Swimming
1
2
3
4
5
4.
Using exercise machine
1
2
3
4
5
VI. Your Diet
1.
How many times last week did you eat breakfast when you got up?
________ times
This morning, did you eat any of the following foods for breakfast? (check all that apply)
2.
Milk (1/2 cup)
Cheese
Yogurt
Eggs
Meat, poultry, or fish
Beans
If you ate anything else, please write here
: _________________________________________________
VII. Medications
1.
In the past week did you take pills for diabetes?
Yes
No
Don’t Know
2.
Please specify the name(s) of the diabetes pills you took: ___________________________________
3.
In the past week did you get insulin injections?
Yes
No
Don’t Know
(Circle one)
VIII. Medical Care
Almost
Some-
Fairly
Very
Never
Always
When you go to your doctor:
never
times
often
often
Do you make a list of questions for your
1.
0
1
2
3
4
5
doctor?
Do you ask questions about the things you
0
1
2
3
4
5
2.
want to know and things you don’t
understand?
Do you talk about things other than your
0
1
2
3
4
5
3.
being sick?
MMH-4
MAR 16
Page 3
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
(Continued)
VIII. Medical Care, Continued
In the past 2 months, how many times did you visit a doctor?
4.
________ visits
(Do not include hospital or ER visits)
In the past 2 months, how many times did you go to a walk-in-clinic for an
5.
________ times
emergency?
In the past 2 months, how many times did you go to a hospital emergency
6.
________ times
room?
In the past 2 months, how many times were you admitted to the hospital
7.
________ times
for one night or longer?
When was the last time you had your eyes examined? (example: for
_____ / _____
8.
glaucoma or any other problem)
Month / Year
How many times did the doctor or nurse examine your feet in the last 6
9.
________ times
months?
IX. Check all that apply:
I am a participant with a sickness.
Yes
No
I take care of someone with a sickness.
Yes
No
X. Have you ever taken this class before?
Yes
No
Unsure
XI. This survey was completed: (check only one)
Without help
With some help
Thank you for completing the survey!
MMH-4
MAR 16
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