10-10138 Mentoring Instruments - Baseline survey, 6 mo. survey, 1

OMB No. 2900-XXXX
Estimated Burden: 1473 hours
Expiration Date: 03/31/2018

Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes –

PACT Demo Lab VISN 4

VA Form 10-10138

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 2-45 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to by evaluating the effects of the VA PACT initiative and by testing new, innovative strategies for patient care that can be spread if proven effective. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

BASELINE SURVEY

CV1. Date enrolled: / /

CV2. Data entered by: (initials)

CV3. Data checked by: (initials)

CV4.

Poorly Controlled Patient 1Peer Mentor 2

CV5. Arm

Control 1

Peer Mentoring 2

FFM 3

Baseline measurements

BM1. Initial HbA1c: _________________________________________

BM2. Blood Pressure 1: _________________________________________

BM3. Blood Pressure 2: _________________________________________

BM4. Blood Pressure Average: _________________________________________

BM5. Direct LDL: _________________________________________

BM6. Height: _________________________________________

BM7. Weight: _________________________________________

BM8. BMI: ______________________________________________

BM9. Primary Care Physician: ________________________________________

DIABETES MEDICATIONS (DM HEALTH HISTORY)

Let’s start with a few questions about your diabetes.

A1. What year were you first told you had diabetes? / /

A2. How old were you when you learned you had diabetes?

A3. What medications do you currently use to treat your diabetes?

	Yes	No
A3A. Oral medications/pills	1	0
A3B. Insulin	1	0

A4. Which of the following medications do you currently take?

Medicine	Yes	No
A4A. Acarbose	1	0
A4B. Chlorpropamide	1	0
A4C. Glimepiride	1	0
A4D. Glipizide	1	0
A4E. Glyburide	1	0
A4F. Insulin Aspart	1	0
A4G. Insulin Detemir (Levemir)	1	0
A4H. Insulin Glargine	1	0
A4I. Insulin Human 50/50	1	0
A4J. Insulin Human 70/30	1	0
A4K. Insulin Lente Pork	1	0
A4L.Insulin Lispro 75/25	1	0
A4M. Insulin NPH Human, Novolin N	1	0
A4N. Insulin NPH Pork	1	0
A4O. Insulin Regular Human, Novolin R	1	0
A4P. Metformin	1	0
A4Q. Nateglinide	1	0
A4R. Pioglitazone	1	0
A4S. Repaglinide	1	0
A4T. Rosiglitazone	1	0
A4U. Sitagliptin	1	0
A4V.Tolazamide	1	0
A4W. Tolbutamide	1	0
A4X. Troglitazone	1	0

If you answered yes to A3B, ask A5-A7:

	Once a Day in the Morning	Once a Day in the Evening	Twice a Day	Three Times a Day	Four or More Times a Day	I use an Infusion Pump
A5. How many times during the day do you usually take your insulin?	1	2	3	4	5	6

A6. How old were you when you started taking insulin? years

A7. Have you taken insulin for as long as you have had diabetes?

Yes	1
No	0

A8. How difficult is it for you to pay for you diabetes medication?

Not at All Difficult	Some What Difficult	Moderately Difficult	Very Difficult	Extremely Difficult
1	2	3	4	5

(HYPOGLYCEMIC SYMPTOMS)

DM Symptoms
	0 Times	1 Time	2 Times	3 Times	4-6 Times	7-12 Times	Don’t Know
A9. How many times in the LAST 3 MONTHS have you had a low blood sugar (glucose) reaction with symptoms such as sweating, weakness, anxiety, trembling, hunger or headaches?	1	2	3	4	5	6	77
A10. 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	2	3	4	5	6	77
A11. How many days in the LAST 3 MONTHS have you had high blood sugar with symptoms such as thirst, dry mouth and skin, less appetite, nausea, or fatigue?	1	2	3	4	5	6	77

IfA10 is greater than 0 then ask:

A11a. Who helped you___________________________?

A11b. What kind of help did they give you_________________________________________?

A11c. Did you have to call 911? Yes 1/No 0

A11d. Did you go to an emergency room? Yes 1/No 0

A11e. Were you admitted to the hospital overnight? Yes 1/No 0

A11f. Is there anything else I should know?__________________________________________

A12. Morisky Medication Adherence (SELF MANAGEMENT BEHAVIOR)

	Yes	No
A12A. Do you ever forget to take your diabetes medicine?	1	0
A12B. Are you always careful about taking your diabetes medicine?	1	0
A12C. When you feel better do you sometimes stop taking your diabetes medicine?	1	0
A12D. Sometimes if you feel worse when you take the diabetes medicine, do you stop taking it?	1	0

DIABETIC COMORBIDITIES (DM HEALTH HISTORY)

The next few questions are about your medical history.

Have you ever been told by a health care provider that you have any of the following problems with your eyes?

	Yes	No
B1. Cataracts	1	0
B2. Glaucoma	1	0
B3. Detached Retina	1	0
B4. Blurred vision (not correctable with eye glasses)	1	0
B5. Retinopathy (diabetic changes in the back of your eye)	1	0
B6. Blindness	1	0

Have you ever had any of the following operations on your eyes?

	Yes	No
B7. Cataracts surgery	1	0
B8. Laser treatment	1	0
B9. Other (specify___________B9A________________)	1	0

Have you ever been told by a health care provider that you have any of the following problems related to your heart or circulation?

	Yes	No
B10. Heart attack	1	0
B11. Heart failure	1	0
B12. High cholesterol	1	0
B13. Angina	1	0
B14. High blood pressure	1	0

Have you ever had any of the following operations or procedures related to your heart?

	Yes	No
B15. Coronary artery bypass surgery (open heart surgery)	1	0
B16. Coronary angioplasty or stent (“balloon’ procedure)	1	0
B17. Heart catheterization (angiogram)	1	0

Have you ever been told by a health care provider that you have any of the following bladder, kidney, or urinary problems?

	Yes	No
B18. Kidney or bladder infections	1	0
B19. Kidney failure	1	0
B20. Protein in your urine	1	0
B21. Prostatitis or inflamed prostate (men only)	1	0
B22. Vaginitis or vaginal infection (women only)	1	0

Have you ever been told by a health care provider that you have any of the following problems with your feet or legs?

	Yes	No
B23. Peripheral vascular disease (poor circulation in the legs)	1	0
B24. Intermittent claudication (cramping in the calves after exercise)	1	0
B25. Peripheral neuropathy (nerve problems causing numbness, tingling, or burning).	1	0
B26. Gangrene	1	0
B27. Foot ulcers	1	0
B28. Athlete’s foot or fungus infection of the feet	1	0

Have you ever had an amputation of the toe, foot, part of a leg, or all of a leg for a poorly healing sore or poor circulation? (An amputation that is NOT due to an injury or accident)?

	Yes	No
B29. Toes	1	0
B30. Part of a foot (or feet)	1	0
B31. Leg, below the knee	1	0
B32. Leg, above the knee	1	0

Have you ever been told by a health care provider that you have had any of the following problems?

	Yes	No
B33. Stroke	1	0
B34. Transient ischemic attacks (TIA or “mini-stroke”)	1	0

B35. Do you currently smoke cigarettes, a pipe or cigars? (GENERAL HEALTH HISTORY)

Yes	1	Skip to Page C
No	0	Proceed

B36. Have you ever smoked cigarettes, a pipe or cigars?

Yes	1	Proceed
No	0	Skip to Page C

B37 How many years ago did you quit smoking?

Number of years

As far as you know, do you have any of the following health conditions at the present time?

C. Charlson Morbidity Scale
	Yes	No	Don’t Know	Refuse
C1. Anemia (low blood) – including sickle cell anemia	1	0	77	99
C2. Asthma, emphysema, or chronic bronchitis	1	0	77	99
C3. Arthritis or rheumatism	1	0	77	99
C4. Back problems (including spine or disk)	1	0	77	99
C5. Cancer, diagnosed in the past 3 years	1	0	77	99
C6. Depression	1	0	77	99
C7. Diabetes	1	0	77	99
C8. Digestive problems (ulcer, colitis, gallbladder disease)	1	0	77	99
C9. High blood pressure	1	0	77	99
C10. HIV illness or AIDS	1	0	77	99
C11. Kidney problems	1	0	77	99
C12. Liver problems (cirrhosis)	1	0	77	99
C13. Stroke	1	0	77	99

D. SF-1 Health Survey ( GENERAL HEALTH HISTORY)

D1. In general, would you say your health is…

Excellent	Very Good	Good	Fair	Poor
1	2	3	4	5

E. Health Utility Index ( GENERAL HEALTH HISTORY)

	Yes	No	Don’t Know	Refused
During the past four weeks, have you been able to see well enough to read ordinary newsprint without glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
Have you been able to see well enough to read ordinary newsprint with glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
During the past four weeks, have you been able to see at all?	1	0	77	99
If no, go to question 6.
During the past four weeks, have you been able to see well enough to recognize a friend on the other side of the street without glasses or contact lenses?	1	0	77	99
If yes, go to question 6.
Have you been able to see well enough to recognize a friend on the other side of the street with glasses or contact lenses?	1	0	77	99
During the past four weeks, have you been able to hear what is said in a group conversation with at least three other people without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a group conversation with at least three other people with a hearing aid?	1	0	77	99
If yes, go to question 9.
During the past four weeks, have you been able to hear at all?	1	0	77	99
If no, go to question 11.
During the past four weeks, have you been able to hear what is said in a conversation with one other person in a quiet room without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a conversation with one other person in a quiet room with a hearing aid?	1	0	77	99
During the past four weeks have you been able to be understood completely when speaking your own language with people who do not know you?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who do not know you?	1	0	77	99
During the past 4 weeks, have you been able to be understood completely when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
During the past four weeks, have you been able to speak at all?	1	0	77	99
During the past four weeks have you been able to bend, lift, jump and run without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood with difficulty but without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
During the past four weeks, have you been able to walk at all?	1	0	77	99
If no, go to question 22.
Have you needed mechanical support, such as braces or a cane or crutches, to be able to walk around the neighborhood?	1	0	77	99
Have you needed the help of another person to walk?	1	0	77	99
Have you needed a wheelchair to get around the neighborhood?	1	0	77	99
Have you needed the help of another person to get around in the wheelchair?	1	0	77	99
During the past four weeks, have you had the full use of both hands and ten fingers?	1	0	77	99
If yes, go to question 28.
Have you needed the help of another person because of limitations in the use of your hands or fingers?	1	0	77	99
If no, go to question 27.

	Some tasks	Most tasks	All tasks	Don’t know	Refused
Have you needed the help of another person with: some tasks, most tasks, or all tasks?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
Have you needed special equipment, for example, special tools to help with dressing or eating, because of limitations in the use of your hands or fingers?	1	0	77	99
During the past four weeks, have you been able to eat, bathe, dress and use the toilet without difficulty?	1	0	77	99
If yes, go to question 31.
Have you needed the help of another person to eat, bathe, dress or use the toilet?	1	0	77	99
Have you needed special equipment or tools to eat, bathe, dress or use the toilet?	1	0	77	99

	Happy	Unhappy	Don’t Know	Refused
During the past four weeks, have you been feeling happy or unhappy?	1	2	77	99
If Unhappy, go to question 33.

	Happy & Interested	Somewhat happy	Don’t Know	Refused
Would you describe yourself as having felt: happy and interested in life, or somewhat happy?	1	2	77	99
If happy or somewhat happy, go to question 34.

	Somewhat unhappy	Very unhappy	So unhappy that life is not worthwhile	Don’t know	Refused
Would you describe yourself as having felt: somewhat unhappy, very unhappy, or so unhappy that life is not worthwhile?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you ever feel fretful, angry, irritable, anxious or depressed?	1	0	77	99
If no, go to question 37.

	Rarely	Occasionally	Often	Almost always	Don’t know	Refused
How often did you feel fretful, angry, irritable, anxious or depressed?	1	2	3	4	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you feel extremely fretful, angry, irritable, anxious or depressed, to the point of needing professional help?	1	0	77	99

	Able to remember most things	Somewhat forgetful	Very forgetful	Unable to remember anything at all	Don’t know	Refused
How would you describe your ability to remember things, during the past four weeks?	1	2	3	4	77	99

	Able to think clearly and solve problems	Had a little difficulty	Had some difficulty	Had a great deal of difficulty	Unable to think or solve problems	Don’t know	Refused
How would you describe your ability to think and solve day to day problems during the past four weeks?	1	2	3	4	5	77	99

	Yes	No	Don’t Know	Refused
Have you had any trouble with pain or discomfort, during the past four weeks?	1	0	77	99
If no, go to question 41.

	None	A few	Some	Most	All	Don’t know	Refused
How many of your activities during the past four weeks were limited by pain or discomfort?	1	2	3	4	5	77	99

	Excellent	Very good	Good	Fair	Poor	Don’t know	Refused
Overall, how would you rate your health during the past week?	1	2	3	4	5	77	99

SELF-EFFICACY

How much do you agree or disagree with each statement? I am able to:

F. Perceived Confidence in Diabetes Scale
	Not at all True	Usually Not True	Sometimes but Infrequently True	Occasionally True	Often True	Usually True	Very True
F1. I feel confident in my ability to manage my diabetes.	1	2	3	4	5	6	7
F2. I feel capable of handling my diabetes now.	1	2	3	4	5	6	7
F3. I am able to do my own routine diabetes care now.	1	2	3	4	5	6	7
F4. I am able to meet the challenges of controlling my diabetes.	1	2	3	4	5	6	7

	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Extremely Confident
F5. How confident are you in your ability to take your diabetes medications exactly as directed by your doctor?	1	2	3	4	5

Perceived DM Control
	Not Very Well	Not Well	Neither Not Well or Well	Well	Very Well
F6. How well do you think you are managing to control you diabetes?	1	2	3	4	5

Perceived Benefits
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
F7. Sticking to my diabetes medication will help prevent diseases (complications) related to diabetes.	1	2	3	4	5
F8. Sticking to my diabetes medication will help me control my diabetes.	1	2	3	4	5
F9. Sticking to my diabetes medication will help me feel better.	1	2	3	4	5
F10. Sticking to my diabetes medication will help me live longer.	1	2	3	4	5

Perceived Barriers
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
F11. I have difficulty remembering when to take my diabetes medication.	1	2	3	4	5
F12.Family problems make it difficult for me to take my diabetes medication regularly.	1	2	3	4	5
F13. I would have to change too many habits to take my diabetes medication regularly.	1	2	3	4	5
F14. Taking my diabetes medication interferes with my normal daily activities.	1	2	3	4	5
F15. I don’t feel motivated to take my diabetes medication regularly.	1	2	3	4	5

SUPPORT NEEDS, RECEIVED, ATTITUDES (SOCIAL SUPPORT) G1. I want a lot of help and support from my family or friends in:

	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G1A. Following my meal plan.	1	2	3	4	5	88
G1B. Taking my medicine.	1	2	3	4	5	88
G1C. Taking care of my feet.	1	2	3	4	5	88
G1D. Getting enough physical activity.	1	2	3	4	5	88
G1E. Testing my sugar.	1	2	3	4	5	88
G1F. Handling my feelings about diabetes.	1	2	3	4	5	88

G2. My family or friends help and support me a lot to:

	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G2A. Follow my meal plan.	1	2	3	4	5	88
G2B.Take my medicine.	1	2	3	4	5	88
G2C. Take care of my feet.	1	2	3	4	5	88
G2D. Get enough physical activity.	1	2	3	4	5	88
G2E. Test my sugar.	1	2	3	4	5	88
G2F. Handle my feelings about diabetes.	1	2	3	4	5	88

G3. My family or friends:

	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G3A. Accept me and my diabetes.	1	2	3	4	5	88
G3B.Feel uncomfortable about me because of my diabetes.	1	2	3	4	5	88
G3C. Encourage or reassure me about my diabetes.	1	2	3	4	5	88
G3D. Discourage or upset me about my diabetes.	1	2	3	4	5	88
G3E. Listen to me when I want to talk about my diabetes.	1	2	3	4	5	88
G3F. Nag me about diabetes.	1	2	3	4	5	88

ATTACHMENT STYLE

Check one box for each statement that best describes how much you agree or disagree with the following statements.

	Strongly disagree	Disagree	Slightly disagree	Slightly agree	Agree	Strongly agree
H1. I find it relatively easy to get close with others.	1	2	3	4	5	6
H2. I’m not very comfortable having to depend on other people.	1	2	3	4	5	6
H3. I’m comfortable having others depend on me.	1	2	3	4	5	6
H4. I rarely worry about being abandoned by others.	1	2	3	4	5	6
H5. I don’t like people getting too close to me.	1	2	3	4	5	6
H6. I’m somewhat uncomfortable being too close to others.	1	2	3	4	5	6
H7. I find it difficult to trust others completely.	1	2	3	4	5	6
H8. I’m nervous whenever anyone gets too close to me.	1	2	3	4	5	6

SELF-MANAGEMENT (from Summary of Diabetes Self-Care Activities Measure)

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.

	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days
I1. How many of the last seven days have you followed a healthful eating plan?	0	1	2	3	4	5	6	7
I2.On average, over the past month, how many days per week have you followed your eating plan?	0	1	2	3	4	5	6	7
I3. On how many of the last seven days did you eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
I4. On how many of the last seven days did you eat high fat foods such as red meat or full-fat dairy products?	0	1	2	3	4	5	6	7
I5. On how many of the last seven days did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking)	0	1	2	3	4	5	6	7
I6. On how many of the last seven days did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
I7. On how many of the last seven days did you test your blood sugar?	0	1	2	3	4	5	6	7
I8. On how many of the last seven days did you test your blood sugar the number of times recommended by your health provider?	0	1	2	3	4	5	6	7
I9. On how many of the last seven days did you check your feet?	0	1	2	3	4	5	6	7
I10. On how many of the last seven days did you inspect the inside of your shoes?	0	1	2	3	4	5	6	7

K. Diabetes Distress Scale (DDS-2 DM QUALITY OF LIFE)

Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. For the following, please consider the degree to which each of the items may have distressed or bothered you during the past month.

	Not a Problem	Minor Problem	Moderate Problem	Somewhat Serious Problem	Serious Problem
K1. Feeling overwhelmed by the demands of living with diabetes	1	2	3	4	5
K2. Feeling that I am often failing with my diabetes regimen	1	2	3	4	5

L. Patient Health Questionnaire (PHQ2 - Depression) (DEPRESSION SYMPTOMS)

Over the last 2 weeks, how often have you been bothered by any of the following problems?
	Not at all	Several Days	More than half the days	Nearly every day
L1. Little interest or pleasure in doing things	0	1	2	3
L2. Feeling down, depressed, or hopeless	0	1	2	3

DEMOGRAPHICS

M1. What is your age?

M2. What is your birth date? / /

M3. What is your sex?

Male	Female
1	2

M4. Do you consider yourself Spanish, Hispanic, or Latino?

Yes	No
1	0

M5. Which of the following describes your racial background? Please say yes to all that apply as I read down the following list.

Race/Ethnicity	Yes	No
M5A. White	1	0
M5B. Black or African American	1	0
M5C. American Indian or Alaska Native	1	0
M5D. Asian	1	0
M5E. Native Hawaiian or other Pacific Islander	1	0
M5F. Other (please specify)____________M5F1_____________	1	0

M6. What is the highest grade or year of school you completed?

Year
Don’t Know	77

M7. What degrees or diplomas have you earned? Please say yes to all that apply.

Degree	Yes	No
M7A. High school diploma or equivalency (GED)	1	0
M7B. Associate degree (junior college)	1	0
M7C. Technical certificate or degree	1	0
M7D. Bachelor’s degree	1	0
M7E. Master’s degree	1	0
M7F. Doctorate or Professional Degree (MD, JD, DDS, etc)	1	0
M7G. Other (please specify) ________________________	1	0
M7H. None of the above (less than high school)	1	0

M8. What is your current marital or domestic status? Please say yes to all that apply.

Status	Yes	No
M8A. Married	1	0
M8B. Living with someone as a couple, but not married	1	0
M8C. Widowed	1	0
M8D. Divorced or Separated	1	0
M8E. Never married	1	0
M8F. Other	1	0

M9. Which best describes your current living situation?

Live alone in your own apartment or house	1
Live with family members	2
Live with friends or roommates in an apartment or house	3
Live in residential treatment	4
Live in a shelter or on the streets	5
Other: ___M9A______________	6

M10. How many people live with you? _______________________________________

M11. Which of the following best describes your current employment status?

Working full-time, 35 or more hours per week	1
Working part-time, less than 35 hours per week	2
Unemployed or laid off and looking for work	3
Unemployed and not looking for work	4
Homemaker	5
In school	6
Retired	7
Disabled, not able to work	8
Other:____________M11A___________	9

M12. How would you describe your care? (check all that apply)

Plan	Yes	No
M12A. Do you get all of your care at the VA?	1	0
M12B. Do you go to see doctors outside of the VA for any reason?	1	0

M13. Which of the categories best describes your total annual combined household income from all sources?

Less than $5,000	1
$5,000 to $9,999	2
$10,000 to $14,999	3
$15,000 to $19,999	4
$20,000 to $29,999	5
$30,000 to $39,999	6
$40,000 to $49,999	7
$50,000 to $59,999	8
$60,000 to $69,999	9
$70,000 and over	10
Don’t Know	77
Refuse to disclose	99

6-MONTH SURVEY

CV1. Date enrolled: / /

CV2. Data entered by: (initials)

CV3. Data checked by: (initials)

CV4.

Poorly Controlled Patient 1

Peer Mentor 2

CV5. Arm

Usual Care 1

Peer Mentoring 2

FFM 3

6-month measurements

SM1. Initial HbA1c: _________________________________________

SM2. Blood Pressure 1: _________________________________________

SM3. Blood Pressure 2: _________________________________________

SM4. Blood Pressure Average: _________________________________________

SM5. Direct LDL: _________________________________________

SM6. Height: _________________________________________

SM7. Weight: _________________________________________

SM8. BMI: ______________________________________________

SM9. Primary Care Physician: ________________________________________

Health Utility Index
	Yes	No	Don’t Know	Refused
During the past four weeks, have you been able to see well enough to read ordinary newsprint without glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
Have you been able to see well enough to read ordinary newsprint with glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
During the past four weeks, have you been able to see at all?	1	0	77	99
If no, go to question 6.
During the past four weeks, have you been able to see well enough to recognize a friend on the other side of the street without glasses or contact lenses?	1	0	77	99
If yes, go to question 6.
Have you been able to see well enough to recognize a friend on the other side of the street with glasses or contact lenses?	1	0	77	99
During the past four weeks, have you been able to hear what is said in a group conversation with at least three other people without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a group conversation with at least three other people with a hearing aid?	1	0	77	99
If yes, go to question 9.
During the past four weeks, have you been able to hear at all?	1	0	77	99
If no, go to question 11.
During the past four weeks, have you been able to hear what is said in a conversation with one other person in a quiet room without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a conversation with one other person in a quiet room with a hearing aid?	1	0	77	99
During the past four weeks have you been able to be understood completely when speaking your own language with people who do not know you?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who do not know you?	1	0	77	99
During the past 4 weeks, have you been able to be understood completely when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
During the past four weeks, have you been able to speak at all?	1	0	77	99
During the past four weeks have you been able to bend, lift, jump and run without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood with difficulty but without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
During the past four weeks, have you been able to walk at all?	1	0	77	99
If no, go to question 22.
Have you needed mechanical support, such as braces or a cane or crutches, to be able to walk around the neighborhood?	1	0	77	99
Have you needed the help of another person to walk?	1	0	77	99
Have you needed a wheelchair to get around the neighborhood?	1	0	77	99
Have you needed the help of another person to get around in the wheelchair?	1	0	77	99
During the past four weeks, have you had the full use of both hands and ten fingers?	1	0	77	99
If yes, go to question 28.
Have you needed the help of another person because of limitations in the use of your hands or fingers?	1	0	77	99
If no, go to question 27.

	Some tasks	Most tasks	All tasks	Don’t know	Refused
Have you needed the help of another person with: some tasks, most tasks, or all tasks?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
Have you needed special equipment, for example, special tools to help with dressing or eating, because of limitations in the use of your hands or fingers?	1	0	77	99
During the past four weeks, have you been able to eat, bathe, dress and use the toilet without difficulty?	1	0	77	99
If yes, go to question 31.
Have you needed the help of another person to eat, bathe, dress or use the toilet?	1	0	77	99
Have you needed special equipment or tools to eat, bathe, dress or use the toilet?	1	0	77	99

	Happy	Unhappy	Don’t Know	Refused
During the past four weeks, have you been feeling happy or unhappy?	1	2	77	99
If Unhappy, go to question 33.

	Happy & Interested	Somewhat happy	Don’t Know	Refused
Would you describe yourself as having felt: happy and interested in life, or somewhat happy?	1	2	77	99
If happy or somewhat happy, go to question 34.

	Somewhat unhappy	Very unhappy	So unhappy that life is not worthwhile	Don’t know	Refused
Would you describe yourself as having felt: somewhat unhappy, very unhappy, or so unhappy that life is not worthwhile?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you ever feel fretful, angry, irritable, anxious or depressed?	1	0	77	99
If no, go to question 37.

	Rarely	Occasionally	Often	Almost always	Don’t know	Refused
How often did you feel fretful, angry, irritable, anxious or depressed?	1	2	3	4	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you feel extremely fretful, angry, irritable, anxious or depressed, to the point of needing professional help?	1	0	77	99

	Able to remember most things	Somewhat forgetful	Very forgetful	Unable to remember anything at all	Don’t know	Refused
How would you describe your ability to remember things, during the past four weeks?	1	2	3	4	77	99

	Able to think clearly and solve problems	Had a little difficulty	Had some difficulty	Had a great deal of difficulty	Unable to think or solve problems	Don’t know	Refused
How would you describe your ability to think and solve day to day problems during the past four weeks?	1	2	3	4	5	77	99

	Yes	No	Don’t Know	Refused
Have you had any trouble with pain or discomfort, during the past four weeks?	1	0	77	99
If no, go to question 41.

	None	A few	Some	Most	All	Don’t know	Refused
How many of your activities during the past four weeks were limited by pain or discomfort?	1	2	3	4	5	77	99

	Excellent	Very good	Good	Fair	Poor	Don’t know	Refused
Overall, how would you rate your health during the past week?	1	2	3	4	5	77	99

As far as you know, do you have any of the following health conditions at the present time?

B. Charlson Morbidity Scale
	Yes	No	Don’t Know	Refuse
B1. Anemia (low blood) – including sickle cell anemia	1	0	77	99
B2. Asthma, emphysema, or chronic bronchitis	1	0	77	99
B3. Arthritis or rheumatism	1	0	77	99
B4. Back problems (including spine or disk)	1	0	77	99
B5. Cancer, diagnosed in the past 3 years	1	0	77	99
B6. Depression	1	0	77	99
B7. Diabetes	1	0	77	99
B8. Digestive problems (ulcer, colitis, gallbladder disease)	1	0	77	99
B9. High blood pressure	1	0	77	99
B10. HIV illness or AIDS	1	0	77	99
B11. Kidney problems	1	0	77	99
B12. Liver problems (cirrhosis)	1	0	77	99
B13. Stroke	1	0	77	99

C. SF-1 Health Survey
C1. In general, would you say your health is…
Excellent	Very Good	Good	Fair	Poor
1	2	3	4	5

D. HYPOGLYCEMIC SYMPTOMS
DM Symptoms
	0 Times	1 Time	2 Times	3 Times	4-6 Times	7-12 Times	Don’t know
1. 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 headaches?	1	2	3	4	5	6	77
2. How many times in the LAST Month have you had severe low blood sugar reactions such as passing out or needing help to treat the reaction?	1	2	3	4	5	6	77
3. How many days in the LAST 3 MONTHS have you had high blood sugar with symptoms such as thirst, dry mouth and skin, less appetite, nausea, or fatigue?	1	2	3	4	5	6	77

E. Diabetes Distress Scale (DDS-2)

Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. For the following, please consider the degree to which each of the items may have distressed or bothered you during the past month.

	Not a Problem	Minor Problem	Moderate Problem	Somewhat Serious Problem	Serious Problem
E1. Feeling overwhelmed by the demands of living with diabetes	1	2	3	4	5
E2. Feeling that I am often failing with my diabetes regimen	1	2	3	4	5

F. Patient Health Questionnaire (PHQ2 - Depression)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
	Not at all	Several Days	More than half the days	Nearly every day
F1. Little interest or pleasure in doing things	0	1	2	3
F2. Feeling down, depressed, or hopeless	0	1	2	3

G. SUPPORT NEEDS, RECEIVED, ATTITUDES (from Diabetes Care Profile)

G1. I want a lot of help and support from my family or friends in:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G1A. Following my meal plan.	1	2	3	4	5	88
G1B. Taking my medicine.	1	2	3	4	5	88
G1C. Taking care of my feet.	1	2	3	4	5	88
G1D. Getting enough physical activity.	1	2	3	4	5	88
G1E. Testing my sugar.	1	2	3	4	5	88
G1F. Handling my feelings about diabetes.	1	2	3	4	5	88

G2. My family or friends help and support me a lot to:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G2A. Follow my meal plan.	1	2	3	4	5	88
G2B.Take my medicine.	1	2	3	4	5	88
G2C. Take care of my feet.	1	2	3	4	5	88
G2D. Get enough physical activity.	1	2	3	4	5	88
G2E. Test my sugar.	1	2	3	4	5	88
G2F. Handle my feelings about diabetes.	1	2	3	4	5	88

G3. My family or friends:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G3A. Accept me and my diabetes.	1	2	3	4	5	88
G3B.Feel uncomfortable about me because of my diabetes.	1	2	3	4	5	88
G3C. Encourage or reassure me about my diabetes.	1	2	3	4	5	88
G3D. Discourage or upset me about my diabetes.	1	2	3	4	5	88
G3E. Listen to me when I want to talk about my diabetes.	1	2	3	4	5	88
G3F. Nag me about diabetes.	1	2	3	4	5	88

SELF-EFFICACY

How much do you agree or disagree with each statement? I am able to:

H. Perceived Confidence in Diabetes Scale
	Not at all True	Usually Not True	Sometimes but Infrequently True	Occasionally True	Often True	Usually True	Very True
H1. I feel confident in my ability to manage my diabetes.	1	2	3	4	5	6	7
H2. I feel capable of handling my diabetes now.	1	2	3	4	5	6	7
H3. I am able to do my own routine diabetes care now.	1	2	3	4	5	6	7
H4. I am able to meet the challenges of controlling my diabetes.	1	2	3	4	5	6	7

	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Extremely Confident
H5. How confident are you in your ability to take your diabetes medications exactly as directed by your doctor?	1	2	3	4	5

Perceived DM Control
	Not Very Well	Not Well	Neither Not Well or Well	Well	Very Well
H6. How well do you think you are managing to control you diabetes?	1	2	3	4	5

Perceived Benefits
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H7. Sticking to my diabetes medication will help prevent diseases (complications) related to diabetes.	1	2	3	4	5
H8. Sticking to my diabetes medication will help me control my diabetes.	1	2	3	4	5
H9. Sticking to my diabetes medication will help me feel better.	1	2	3	4	5
H10. Sticking to my diabetes medication will help me live longer.	1	2	3	4	5

Perceived Barriers
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H11. I have difficulty remembering when to take my diabetes medication.	1	2	3	4	5
H12.Family problems make it difficult for me to take my diabetes medication regularly.	1	2	3	4	5
H13. I would have to change too many habits to take my diabetes medication regularly.	1	2	3	4	5
H14. Taking my diabetes medication interferes with my normal daily activities.	1	2	3	4	5
H15. I don’t feel motivated to take my diabetes medication regularly.	1	2	3	4	5

H16. Morisky Medication Adherence (SELF MANAGEMENT BEHAVIOR)

	Yes	No
H16A. Do you ever forget to take your diabetes medicine?	1	0
H16B. Are you always careful about taking your diabetes medicine?	1	0
H16C. When you feel better do you sometimes stop taking your diabetes medicine?	1	0
H16D. Sometimes if you feel worse when you take the diabetes medicine, do you stop taking it?	1	0

H17. During the past 6 months, did you start using insulin?

H17A. If yes, do you know the name of your insulin? _____________________________________________

	Once a Day in the Morning	Once a Day in the Evening	Twice a Day	Three Times a Day	Four or More Times a Day	I use an Infusion Pump
H18. How many times during the day do you usually take your insulin?	1	2	3	4	5	6

H19. How old were you when you started taking insulin?                                                   years

H20. Have you taken insulin for as long as you have had diabetes?

Yes	1
No	0

1. SELF-MANAGEMENT (from Summary of Diabetes Self-Care Activities Measure)

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.

	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days
I1. How many of the last seven days have you followed a healthful eating plan?	0	1	2	3	4	5	6	7
I2.On average, over the past month, how many days per week have you followed your eating plan?	0	1	2	3	4	5	6	7
I3. On how many of the last seven days did you eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
I4. On how many of the last seven days did you eat high fat foods such as red meat or full-fat dairy products?	0	1	2	3	4	5	6	7
I5. On how many of the last seven days did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking)	0	1	2	3	4	5	6	7
I6. On how many of the last seven days did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
I7. On how many of the last seven days did you test your blood sugar?	0	1	2	3	4	5	6	7
I8. On how many of the last seven days did you test your blood sugar the number of times recommended by your health provider?	0	1	2	3	4	5	6	7
I9. On how many of the last seven days did you check your feet?	0	1	2	3	4	5	6	7
I10. On how many of the last seven days did you inspect the inside of your shoes?	0	1	2	3	4	5	6	7

The next few questions are about the money you may have spent to improve your diabetes control during the last 6 months. Please answer yes or no to whether you have bought any of the following during the study.

	Yes		No			Estimated cost
J1. Weight loss program (Weight Watchers, Jenny Craig, Optifast, Nutrasystem, Overeater’s Anonymous, etc.)	1		0			J1A
J2. Vitamins, diet pills, supplements	1		0			J2A
J3. Cookbooks	1		0			J3A
J4. Cooking videos	1		0			J4A
J5. Blender	1		0			J5A
J6. Microwave	1		0			J6A
J7. Steamer	1		0			J7A
J8. Pots and pans for low fat cooking	1		0			J8A
J9. Mixer or food processor	1		0			J9A
J10. Food scale	1		0			J10A
J11. Freezer	1		0			J11A
J12. Wok or electric grill	1		0			J12A
J13. Other food related items (please specify):	1		0			J13A
	Yes			No		Estimated cost
J14. Bicycle	1			0		J14A
J15. Exercise videos (Wii fit, Tae Bo, P90X, etc.)	1			0		J15A
J16. Free weights, dumbbells, hand & ankle weights	1			0		J16A
J17. Home gym	1			0		J17A
J18. Stationary bicycle	1			0		J18A
J19. Rowing or skiing machine, stair stepper	1			0		J19A
J20. Treadmill	1			0		J20A
J21. Sport or water aerobics equipment (basketball, volleyball, tennis racket, etc.)	1			0		J21A
J22, Health or gym club membership	1			0		J22A
J23. Exercise, aerobic, yoga, or dance class	1			0		J23A
J24. Personal trainer	1			0		J24A
J25. Exercise sneakers	1			0		J25A
J26. Exercise clothing (socks, underwear, special shoes, etc.)	1			0		J26A
J27. Other fitness related items (please specify):	1			0		J27A
		Yes			No			Estimated cost
J28. Is there anything else you bought to help you control your diabetes that we haven’t already mentioned? Please specify:		1			0			J28A

Now I have some additional questions.

J29. In the past 6 months, how much extra money did you spend on average per week for diabetes friendly foods or extra fruits and vegetables?

_____________________

J30. In the last 6 months, how much in total have you paid for your diabetes prescriptions (pills, insulin, etc.)?

_____________________

J31. In the last 6 months, how much money have you paid for diabetic supplies (strips, lancets, Glucometers, etc.)?

_____________________

J32. In the past 6 months, how much money have you spent on special clothing for exercise (athletic clothing, supportive underwear, special shoes like cleats)?

_____________________

J33. In a normal week, how many hours do you yourself spend shopping for and preparing food for yourself?

_____________________

J34. In a normal week, how many hours do your spouse, family, and friends spend shopping and preparing food for you?

J35. How much time does it take you to travel to your Improving Diabetic Outcomes (IDO research study) visit?

_____________________

J36. Did you visit any of the following doctors/healthcare providers during the study?

	Yes	No	# of visits	Copay
J36A. Primary care provider	1	0	J36A1	J36A2
J36B. Nurse practitioner	1	0	J36B1	J36B2
J36C. Endocrinologist	1	0	J36C1	J36C2
J36D. Cardiologist	1	0	J36D1	J36D2
J36E. Ophthalmologist	1	0	J36E1	J36E2
J36F. Podiatrist	1	0	J36F1	J36F2
J36G. Dentist	1	0	J36G1	J36G2

	Yes	No	# of visits	Copay
J36H. Did you have to visit the emergency room during the last 6 months?	1	0	J36H1	J36H2
If yes, why were you admitted?	J36H3
J36I Did you have to stay overnight in the hospital during the last 6 months?	1	0	J36I1	J36I2
If yes, why were you admitted?	J36I3
J36J. Did you have any surgeries during the past 6 months?	1	0	J36J1	J36J2
If yes, what was the surgery?	J36J2

FOLLOW-UP SURVEY

• 6 Month Follow-up ______

• 12 Month Follow-up _______

CV1. Date enrolled: / /

CV2. Data entered by: (initials)

CV3. Data checked by: (initials)

CV4.

Poorly Controlled Patient 1

Peer Mentor 2

CV5.

Arm

Usual Care 1

Peer Mentoring 2

FFM 3

12-month measurements

TM1. Initial HbA1c: _________________________________________

TM2. Blood Pressure 1: _________________________________________

TM3. Blood Pressure 2: _________________________________________

TM4. Blood Pressure Average: _________________________________________

TM5. Direct LDL: _________________________________________

TM6. Height: _________________________________________

TM7. Weight: _________________________________________

TM8. BMI: ______________________________________________

TM9. Primary Care Physician: ________________________________________

Health Utility Index
	Yes	No	Don’t Know	Refused
During the past four weeks, have you been able to see well enough to read ordinary newsprint without glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
Have you been able to see well enough to read ordinary newsprint with glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
During the past four weeks, have you been able to see at all?	1	0	77	99
If no, go to question 6.
During the past four weeks, have you been able to see well enough to recognize a friend on the other side of the street without glasses or contact lenses?	1	0	77	99
If yes, go to question 6.
Have you been able to see well enough to recognize a friend on the other side of the street with glasses or contact lenses?	1	0	77	99
During the past four weeks, have you been able to hear what is said in a group conversation with at least three other people without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a group conversation with at least three other people with a hearing aid?	1	0	77	99
If yes, go to question 9.
During the past four weeks, have you been able to hear at all?	1	0	77	99
If no, go to question 11.
During the past four weeks, have you been able to hear what is said in a conversation with one other person in a quiet room without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a conversation with one other person in a quiet room with a hearing aid?	1	0	77	99
During the past four weeks have you been able to be understood completely when speaking your own language with people who do not know you?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who do not know you?	1	0	77	99
During the past 4 weeks, have you been able to be understood completely when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
During the past four weeks, have you been able to speak at all?	1	0	77	99
During the past four weeks have you been able to bend, lift, jump and run without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood with difficulty but without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
During the past four weeks, have you been able to walk at all?	1	0	77	99
If no, go to question 22.
Have you needed mechanical support, such as braces or a cane or crutches, to be able to walk around the neighborhood?	1	0	77	99
Have you needed the help of another person to walk?	1	0	77	99
Have you needed a wheelchair to get around the neighborhood?	1	0	77	99
Have you needed the help of another person to get around in the wheelchair?	1	0	77	99
During the past four weeks, have you had the full use of both hands and ten fingers?	1	0	77	99
If yes, go to question 28.
Have you needed the help of another person because of limitations in the use of your hands or fingers?	1	0	77	99
If no, go to question 27.

	Some tasks	Most tasks	All tasks	Don’t know	Refused
Have you needed the help of another person with: some tasks, most tasks, or all tasks?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
Have you needed special equipment, for example, special tools to help with dressing or eating, because of limitations in the use of your hands or fingers?	1	0	77	99
During the past four weeks, have you been able to eat, bathe, dress and use the toilet without difficulty?	1	0	77	99
If yes, go to question 31.
Have you needed the help of another person to eat, bathe, dress or use the toilet?	1	0	77	99
Have you needed special equipment or tools to eat, bathe, dress or use the toilet?	1	0	77	99

	Happy	Unhappy	Don’t Know	Refused
During the past four weeks, have you been feeling happy or unhappy?	1	2	77	99
If Unhappy, go to question 33.

	Happy & Interested	Somewhat happy	Don’t Know	Refused
Would you describe yourself as having felt: happy and interested in life, or somewhat happy?	1	2	77	99
If happy or somewhat happy, go to question 34.

	Somewhat unhappy	Very unhappy	So unhappy that life is not worthwhile	Don’t know	Refused
Would you describe yourself as having felt: somewhat unhappy, very unhappy, or so unhappy that life is not worthwhile?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you ever feel fretful, angry, irritable, anxious or depressed?	1	0	77	99
If no, go to question 37.

	Rarely	Occasionally	Often	Almost always	Don’t know	Refused
How often did you feel fretful, angry, irritable, anxious or depressed?	1	2	3	4	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you feel extremely fretful, angry, irritable, anxious or depressed, to the point of needing professional help?	1	0	77	99

	Able to remember most things	Somewhat forgetful	Very forgetful	Unable to remember anything at all	Don’t know	Refused
How would you describe your ability to remember things, during the past four weeks?	1	2	3	4	77	99

	Able to think clearly and solve problems	Had a little difficulty	Had some difficulty	Had a great deal of difficulty	Unable to think or solve problems	Don’t know	Refused
How would you describe your ability to think and solve day to day problems during the past four weeks?	1	2	3	4	5	77	99

	Yes	No	Don’t Know	Refused
Have you had any trouble with pain or discomfort, during the past four weeks?	1	0	77	99
If no, go to question 41.

	None	A few	Some	Most	All	Don’t know	Refused
How many of your activities during the past four weeks were limited by pain or discomfort?	1	2	3	4	5	77	99

	Excellent	Very good	Good	Fair	Poor	Don’t know	Refused
Overall, how would you rate your health during the past week?	1	2	3	4	5	77	99

As far as you know, do you have any of the following health conditions at the present time?

B. Charlson Morbidity Scale
	Yes	No	Don’t Know	Refuse
B1. Anemia (low blood) – including sickle cell anemia	1	0	77	99
B2. Asthma, emphysema, or chronic bronchitis	1	0	77	99
B3. Arthritis or rheumatism	1	0	77	99
B4. Back problems (including spine or disk)	1	0	77	99
B5. Cancer, diagnosed in the past 3 years	1	0	77	99
B6. Depression	1	0	77	99
B7. Diabetes	1	0	77	99
B8. Digestive problems (ulcer, colitis, gallbladder disease)	1	0	77	99
B9. High blood pressure	1	0	77	99
B10. HIV illness or AIDS	1	0	77	99
B11. Kidney problems	1	0	77	99
B12. Liver problems (cirrhosis)	1	0	77	99
B13. Stroke	1	0	77	99

C. SF-1 Health Survey
C1. In general, would you say your health is…
Excellent	Very Good	Good	Fair	Poor
1	2	3	4	5

D. HYPOGLYCEMIC SYMPTOMS
DM Symptoms
	0 Times	1 Time	2 Times	3 Times	4-6 Times	7-12 Times	Don’t know
1. 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 headaches?	1	2	3	4	5	6	77
2. How many times in the LAST Month have you had severe low blood sugar reactions such as passing out or needing help to treat the reaction?	1	2	3	4	5	6	77
3. How many days in the LAST 3 MONTHS have you had high blood sugar with symptoms such as thirst, dry mouth and skin, less appetite, nausea, or fatigue?	1	2	3	4	5	6	77

E. Diabetes Distress Scale (DDS-2)

Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. For the following, please consider the degree to which each of the items may have distressed or bothered you during the past month.

	Not a Problem	Minor Problem	Moderate Problem	Somewhat Serious Problem	Serious Problem
E1. Feeling overwhelmed by the demands of living with diabetes	1	2	3	4	5
E2. Feeling that I am often failing with my diabetes regimen	1	2	3	4	5

F. Patient Health Questionnaire (PHQ2 - Depression)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
	Not at all	Several Days	More than half the days	Nearly every day
F1. Little interest or pleasure in doing things	0	1	2	3
F2. Feeling down, depressed, or hopeless	0	1	2	3

G. SUPPORT NEEDS, RECEIVED, ATTITUDES (from Diabetes Care Profile)

G1. I want a lot of help and support from my family or friends in:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G1A. Following my meal plan.	1	2	3	4	5	88
G1B. Taking my medicine.	1	2	3	4	5	88
G1C. Taking care of my feet.	1	2	3	4	5	88
G1D. Getting enough physical activity.	1	2	3	4	5	88
G1E. Testing my sugar.	1	2	3	4	5	88
G1F. Handling my feelings about diabetes.	1	2	3	4	5	88

G2. My family or friends help and support me a lot to:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G2A. Follow my meal plan.	1	2	3	4	5	88
G2B.Take my medicine.	1	2	3	4	5	88
G2C. Take care of my feet.	1	2	3	4	5	88
G2D. Get enough physical activity.	1	2	3	4	5	88
G2E. Test my sugar.	1	2	3	4	5	88
G2F. Handle my feelings about diabetes.	1	2	3	4	5	88

G3. My family or friends:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G3A. Accept me and my diabetes.	1	2	3	4	5	88
G3B.Feel uncomfortable about me because of my diabetes.	1	2	3	4	5	88
G3C. Encourage or reassure me about my diabetes.	1	2	3	4	5	88
G3D. Discourage or upset me about my diabetes.	1	2	3	4	5	88
G3E. Listen to me when I want to talk about my diabetes.	1	2	3	4	5	88
G3F. Nag me about diabetes.	1	2	3	4	5	88

SELF-EFFICACY

How much do you agree or disagree with each statement? I am able to:

H. Perceived Confidence in Diabetes Scale
	Not at all True	Usually Not True	Sometimes but Infrequently True	Occasionally True	Often True	Usually True	Very True
H1. I feel confident in my ability to manage my diabetes.	1	2	3	4	5	6	7
H2. I feel capable of handling my diabetes now.	1	2	3	4	5	6	7
H3. I am able to do my own routine diabetes care now.	1	2	3	4	5	6	7
H4. I am able to meet the challenges of controlling my diabetes.	1	2	3	4	5	6	7

	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Extremely Confident
H5. How confident are you in your ability to take your diabetes medications exactly as directed by your doctor?	1	2	3	4	5

Perceived DM Control
	Not Very Well	Not Well	Neither Not Well or Well	Well	Very Well
H6. How well do you think you are managing to control you diabetes?	1	2	3	4	5

Perceived Benefits
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H7. Sticking to my diabetes medication will help prevent diseases (complications) related to diabetes.	1	2	3	4	5
H8. Sticking to my diabetes medication will help me control my diabetes.	1	2	3	4	5
H9. Sticking to my diabetes medication will help me feel better.	1	2	3	4	5
H10. Sticking to my diabetes medication will help me live longer.	1	2	3	4	5

Perceived Barriers
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H11. I have difficulty remembering when to take my diabetes medication.	1	2	3	4	5
H12.Family problems make it difficult for me to take my diabetes medication regularly.	1	2	3	4	5
H13. I would have to change too many habits to take my diabetes medication regularly.	1	2	3	4	5
H14. Taking my diabetes medication interferes with my normal daily activities.	1	2	3	4	5
H15. I don’t feel motivated to take my diabetes medication regularly.	1	2	3	4	5

H16. Morisky Medication Adherence (SELF MANAGEMENT BEHAVIOR)

	Yes	No
A. Do you ever forget to take your diabetes medicine?	1	0
B. Are you always careful about taking your diabetes medicine?	1	0
C. When you feel better do you sometimes stop taking your diabetes medicine?	1	0
D. Sometimes if you feel worse when you take the diabetes medicine, do you stop taking it?	1	0

H17. During the past 6 months, did you start using insulin?

H17A. If yes, do you know the name of your insulin? _____________________________________________

	Once a Day in the Morning	Once a Day in the Evening	Twice a Day	Three Times a Day	Four or More Times a Day	I use an Infusion Pump
H18. How many times during the day do you usually take your insulin?	1	2	3	4	5	6

H19. How old were you when you started taking insulin?                                                   years

H20. Have you taken insulin for as long as you have had diabetes?

Yes	1
No	0

2. SELF-MANAGEMENT (from Summary of Diabetes Self-Care Activities Measure)

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.

	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days
I1. How many of the last seven days have you followed a healthful eating plan?	0	1	2	3	4	5	6	7
I2.On average, over the past month, how many days per week have you followed your eating plan?	0	1	2	3	4	5	6	7
I3. On how many of the last seven days did you eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
I4. On how many of the last seven days did you eat high fat foods such as red meat or full-fat dairy products?	0	1	2	3	4	5	6	7
I5. On how many of the last seven days did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking)	0	1	2	3	4	5	6	7
I6. On how many of the last seven days did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
I7. On how many of the last seven days did you test your blood sugar?	0	1	2	3	4	5	6	7
I8. On how many of the last seven days did you test your blood sugar the number of times recommended by your health provider?	0	1	2	3	4	5	6	7
I9. On how many of the last seven days did you check your feet?	0	1	2	3	4	5	6	7
I10. On how many of the last seven days did you inspect the inside of your shoes?	0	1	2	3	4	5	6	7

J. The next few questions are about the money you may have spent to improve your diabetes control during the last 6 months. Please answer yes or no to whether you have bought any of the following during the study.

	Yes	No	Estimated cost
J1. Weight loss program (Weight Watchers, Jenny Craig, Optifast, Nutrasystem, Overeater’s Anonymous, etc.)	1	0	J1A
J2. Vitamins, diet pills, supplements	1	0	J2A
J3. Cookbooks	1	0	J3A
J4. Cooking videos	1	0	J4A
J5. Blender	1	0	J5A
J6. Microwave	1	0	J6A
J7. Steamer	1	0	J7A
J8. Pots and pans for low fat cooking	1	0	J8A
J9. Mixer or food processor	1	0	J9A
J10. Food scale	1	0	J10A
J11. Freezer	1	0	J11A
J12. Wok or electric grill	1	0	J12A
J13. Other food related items (please specify):	1	0	J13A

	Yes	No	Estimated cost
J14. Bicycle	1	0	J14A
J15. Exercise videos (Wii fit, Tae Bo, P90X, etc.)	1	0	J15A
J16. Free weights, dumbbells, hand & ankle weights	1	0	J16A
J17. Home gym	1	0	J17A
J18. Stationary bicycle	1	0	J18A
J19. Rowing or skiing machine, stair stepper	1	0	J19A
J20. Treadmill	1	0	J20A
J21. Sport or water aerobics equipment (basketball, volleyball, tennis racket, etc.)	1	0	J21A
J22. Health or gym club membership	1	0	J22A
J23. Exercise, aerobic, yoga, or dance class	1	0	J23A
J24. Personal trainer	1	0	J24A
J25. Exercise sneakers	1	0	J25A
J26. Exercise clothing (socks, underwear, special shoes, etc.)	1	0	J26A
J27. Other fitness related items (please specify):	1	0	J27A

	Yes	No	Estimated cost
J28. Is there anything else you bought to help you control your diabetes that we haven’t already mentioned? Please specify:	1	0	J28A

Now I have some additional questions.

J29. In the past 6 months, how much extra money did you spend on average per week for diabetes friendly foods or extra fruits and vegetables?

_____________________

2. J30. In the last 6 months, how much in total have you paid for your diabetes prescriptions (pills, insulin, etc.)?

_____________________

3. J31. In the last 6 months, how much money have you paid for diabetic supplies (strips, lancets, Glucometers, etc.)?

_____________________

4. J32. In the past 6 months, how much money have you spent on special clothing for exercise (athletic clothing, supportive underwear, special shoes like cleats)?

_____________________

5. J33. In a normal week, how many hours do you yourself spend shopping for and preparing food for yourself?

_____________________

6. J34. In a normal week, how many hours do your spouse, family, and friends spend shopping and preparing food for you?

7. J35, How much time does it take you to travel to your Improving Diabetic Outcomes (IDO research study) visit?

_____________________

8. J36. Did you visit any of the following doctors/healthcare providers during the study?

	Yes	No	# of visits	Copay
J36A. Primary care provider	1	0	J36A1	J36A2
J36B. Nurse practitioner	1	0	J36B1	J36B2
J36C. Endocrinologist	1	0	J36C1	J36C2
J36D. Cardiologist	1	0	J36D1	J36D2
J36E. Ophthalmologist	1	0	J36E1	J36E2
J36F. Podiatrist	1	0	J36F1	J36F2
J36G. Dentist	1	0	J36G1	J36G2

	Yes	No	# of visits	Copay
J36H. Did you have to visit the emergency room during the last 6 months?	1	0	J36H1	J36H2
If yes, why were you admitted?	J36H3
J36I. Did you have to stay overnight in the hospital during the last 6 months?	1	0	J36I1	J36I2
If yes, why were you admitted?	J36I3
J36J. Did you have any surgeries during the past 6 months?	1	0	J36J1	J36J2
If yes, what was the surgery?	J36J3

Monthly Script Peer Mentor

Monthly Calls

CV 1. Date enrolled: / /

CV2. Date of phone call: / /

Check in: ______1 month _______3 month

Monthly Script Peer Mentor

Hello this is ________________________________ from the diabetes study at the VA.

Is ___________________________________ there?

- No, when might be a good time for me to call back to get____________________?

- Yes, would this be an ok time to talk for 5 minutes?

-No, when should I call back_________________________

-Yes, great.

1. Did you talk to __________________ in the past 30 days? Yes 1/No 0

1a. If no, why not? ______________________________________________________

1b. If Yes. How many times did you talk to them? ___________________________

2. How did it go?____________________________________________________________

3. Do you have any concerns?_________________________________________________

4. Did you use the take home sheets to guide your conversation?______________________

4a. [if no] Why not?____________________________________________________

4b. [if yes] Did you find it helpful? How so? __________________________________

5. What were some of the topics you discussed?____________________________________

6. What were some of the barriers they felt they were facing to getting their diabetes in control?

____________________________________________________________________________

7. What are his/her goals?______________________________________________________

8. Were you able to help him/her come up with a realistic plan?_________________________

9. Are they able to follow the plan?_______________________________________________

10. Is there something you would like to discuss in regards to mentoring?_________________

10a. [if yes] What is it_____________________________________________________

10b. follow-up until all issues raised__________________________________________

11. [If spoke to mentee 4 or more times] Would you like to schedule a time to come and pick up your voucher for talking to your mentee 4 or more times?____________________________________________________________________

(We do not send payments by mail)

Thank you, I will call again next month.

Begin - 18 Month Survey

FOLLOW-UP SURVEY

• 6 Month Follow-up ______

• 12 Month Follow-up _______

• 18 Month Follow-up _______

CV1. Date enrolled: / /

CV2. Data entered by: (initials)

CV3. Data checked by: (initials)

CV4.

Poorly Controlled Patient 1

Peer Mentor 2

CV5.

Arm

Usual Care 1

Peer Mentoring 2

FFM 3

12-month measurements

TM1. Initial HbA1c: _________________________________________

TM2. Blood Pressure 1: _________________________________________

TM3. Blood Pressure 2: _________________________________________

TM4. Blood Pressure Average: _________________________________________

TM5. Direct LDL: _________________________________________

TM6. Height: _________________________________________

TM7. Weight: _________________________________________

TM8. BMI: ______________________________________________

TM9. Primary Care Physician: ________________________________________

Health Utility Index
	Yes	No	Don’t Know	Refused
During the past four weeks, have you been able to see well enough to read ordinary newsprint without glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
Have you been able to see well enough to read ordinary newsprint with glasses or contact lenses?	1	0	77	99
If yes, go to question 4.
During the past four weeks, have you been able to see at all?	1	0	77	99
If no, go to question 6.
During the past four weeks, have you been able to see well enough to recognize a friend on the other side of the street without glasses or contact lenses?	1	0	77	99
If yes, go to question 6.
Have you been able to see well enough to recognize a friend on the other side of the street with glasses or contact lenses?	1	0	77	99
During the past four weeks, have you been able to hear what is said in a group conversation with at least three other people without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a group conversation with at least three other people with a hearing aid?	1	0	77	99
If yes, go to question 9.
During the past four weeks, have you been able to hear at all?	1	0	77	99
If no, go to question 11.
During the past four weeks, have you been able to hear what is said in a conversation with one other person in a quiet room without a hearing aid?	1	0	77	99
If yes, go to question 11.
Have you been able to hear what is said in a conversation with one other person in a quiet room with a hearing aid?	1	0	77	99
During the past four weeks have you been able to be understood completely when speaking your own language with people who do not know you?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who do not know you?	1	0	77	99
During the past 4 weeks, have you been able to be understood completely when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
Have you been able to be understood partially when speaking with people who know you well?	1	0	77	99
If yes, go to question 16.
During the past four weeks, have you been able to speak at all?	1	0	77	99
During the past four weeks have you been able to bend, lift, jump and run without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood without difficulty and without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
Have you been able to walk around the neighborhood with difficulty but without help or equipment of any kind?	1	0	77	99
If yes, go to question 24.
During the past four weeks, have you been able to walk at all?	1	0	77	99
If no, go to question 22.
Have you needed mechanical support, such as braces or a cane or crutches, to be able to walk around the neighborhood?	1	0	77	99
Have you needed the help of another person to walk?	1	0	77	99
Have you needed a wheelchair to get around the neighborhood?	1	0	77	99
Have you needed the help of another person to get around in the wheelchair?	1	0	77	99
During the past four weeks, have you had the full use of both hands and ten fingers?	1	0	77	99
If yes, go to question 28.
Have you needed the help of another person because of limitations in the use of your hands or fingers?	1	0	77	99
If no, go to question 27.

	Some tasks	Most tasks	All tasks	Don’t know	Refused
Have you needed the help of another person with: some tasks, most tasks, or all tasks?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
Have you needed special equipment, for example, special tools to help with dressing or eating, because of limitations in the use of your hands or fingers?	1	0	77	99
During the past four weeks, have you been able to eat, bathe, dress and use the toilet without difficulty?	1	0	77	99
If yes, go to question 31.
Have you needed the help of another person to eat, bathe, dress or use the toilet?	1	0	77	99
Have you needed special equipment or tools to eat, bathe, dress or use the toilet?	1	0	77	99

	Happy	Unhappy	Don’t Know	Refused
During the past four weeks, have you been feeling happy or unhappy?	1	2	77	99
If Unhappy, go to question 33.

	Happy & Interested	Somewhat happy	Don’t Know	Refused
Would you describe yourself as having felt: happy and interested in life, or somewhat happy?	1	2	77	99
If happy or somewhat happy, go to question 34.

	Somewhat unhappy	Very unhappy	So unhappy that life is not worthwhile	Don’t know	Refused
Would you describe yourself as having felt: somewhat unhappy, very unhappy, or so unhappy that life is not worthwhile?	1	2	3	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you ever feel fretful, angry, irritable, anxious or depressed?	1	0	77	99
If no, go to question 37.

	Rarely	Occasionally	Often	Almost always	Don’t know	Refused
How often did you feel fretful, angry, irritable, anxious or depressed?	1	2	3	4	77	99

	Yes	No	Don’t Know	Refused
During the past four weeks, did you feel extremely fretful, angry, irritable, anxious or depressed, to the point of needing professional help?	1	0	77	99

	Able to remember most things	Somewhat forgetful	Very forgetful	Unable to remember anything at all	Don’t know	Refused
How would you describe your ability to remember things, during the past four weeks?	1	2	3	4	77	99

	Able to think clearly and solve problems	Had a little difficulty	Had some difficulty	Had a great deal of difficulty	Unable to think or solve problems	Don’t know	Refused
How would you describe your ability to think and solve day to day problems during the past four weeks?	1	2	3	4	5	77	99

	Yes	No	Don’t Know	Refused
Have you had any trouble with pain or discomfort, during the past four weeks?	1	0	77	99
If no, go to question 41.

	None	A few	Some	Most	All	Don’t know	Refused
How many of your activities during the past four weeks were limited by pain or discomfort?	1	2	3	4	5	77	99

	Excellent	Very good	Good	Fair	Poor	Don’t know	Refused
Overall, how would you rate your health during the past week?	1	2	3	4	5	77	99

As far as you know, do you have any of the following health conditions at the present time?

B. Charlson Morbidity Scale
	Yes	No	Don’t Know	Refuse
B1. Anemia (low blood) – including sickle cell anemia	1	0	77	99
B2. Asthma, emphysema, or chronic bronchitis	1	0	77	99
B3. Arthritis or rheumatism	1	0	77	99
B4. Back problems (including spine or disk)	1	0	77	99
B5. Cancer, diagnosed in the past 3 years	1	0	77	99
B6. Depression	1	0	77	99
B7. Diabetes	1	0	77	99
B8. Digestive problems (ulcer, colitis, gallbladder disease)	1	0	77	99
B9. High blood pressure	1	0	77	99
B10. HIV illness or AIDS	1	0	77	99
B11. Kidney problems	1	0	77	99
B12. Liver problems (cirrhosis)	1	0	77	99
B13. Stroke	1	0	77	99

C. SF-1 Health Survey
C1. In general, would you say your health is…
Excellent	Very Good	Good	Fair	Poor
1	2	3	4	5

D. HYPOGLYCEMIC SYMPTOMS
DM Symptoms
	0 Times	1 Time	2 Times	3 Times	4-6 Times	7-12 Times	Don’t know
1. 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 headaches?	1	2	3	4	5	6	77
2. How many times in the LAST Month have you had severe low blood sugar reactions such as passing out or needing help to treat the reaction?	1	2	3	4	5	6	77
3. How many days in the LAST 3 MONTHS have you had high blood sugar with symptoms such as thirst, dry mouth and skin, less appetite, nausea, or fatigue?	1	2	3	4	5	6	77

E. Diabetes Distress Scale (DDS-2)

Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. For the following, please consider the degree to which each of the items may have distressed or bothered you during the past month.

	Not a Problem	Minor Problem	Moderate Problem	Somewhat Serious Problem	Serious Problem
E1. Feeling overwhelmed by the demands of living with diabetes	1	2	3	4	5
E2. Feeling that I am often failing with my diabetes regimen	1	2	3	4	5

F. Patient Health Questionnaire (PHQ2 - Depression)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
	Not at all	Several Days	More than half the days	Nearly every day
F1. Little interest or pleasure in doing things	0	1	2	3
F2. Feeling down, depressed, or hopeless	0	1	2	3

G. SUPPORT NEEDS, RECEIVED, ATTITUDES (from Diabetes Care Profile)

G1. I want a lot of help and support from my family or friends in:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G1A. Following my meal plan.	1	2	3	4	5	88
G1B. Taking my medicine.	1	2	3	4	5	88
G1C. Taking care of my feet.	1	2	3	4	5	88
G1D. Getting enough physical activity.	1	2	3	4	5	88
G1E. Testing my sugar.	1	2	3	4	5	88
G1F. Handling my feelings about diabetes.	1	2	3	4	5	88

G2. My family or friends help and support me a lot to:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G2A. Follow my meal plan.	1	2	3	4	5	88
G2B.Take my medicine.	1	2	3	4	5	88
G2C. Take care of my feet.	1	2	3	4	5	88
G2D. Get enough physical activity.	1	2	3	4	5	88
G2E. Test my sugar.	1	2	3	4	5	88
G2F. Handle my feelings about diabetes.	1	2	3	4	5	88

G3. My family or friends:
	Strongly disagree	Somewhat disagree	Neutral	Somewhat agree	Strongly agree	Does not apply
G3A. Accept me and my diabetes.	1	2	3	4	5	88
G3B.Feel uncomfortable about me because of my diabetes.	1	2	3	4	5	88
G3C. Encourage or reassure me about my diabetes.	1	2	3	4	5	88
G3D. Discourage or upset me about my diabetes.	1	2	3	4	5	88
G3E. Listen to me when I want to talk about my diabetes.	1	2	3	4	5	88
G3F. Nag me about diabetes.	1	2	3	4	5	88

SELF-EFFICACY

How much do you agree or disagree with each statement? I am able to:

H. Perceived Confidence in Diabetes Scale
	Not at all True	Usually Not True	Sometimes but Infrequently True	Occasionally True	Often True	Usually True	Very True
H1. I feel confident in my ability to manage my diabetes.	1	2	3	4	5	6	7
H2. I feel capable of handling my diabetes now.	1	2	3	4	5	6	7
H3. I am able to do my own routine diabetes care now.	1	2	3	4	5	6	7
H4. I am able to meet the challenges of controlling my diabetes.	1	2	3	4	5	6	7

	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Extremely Confident
H5. How confident are you in your ability to take your diabetes medications exactly as directed by your doctor?	1	2	3	4	5

Perceived DM Control
	Not Very Well	Not Well	Neither Not Well or Well	Well	Very Well
H6. How well do you think you are managing to control you diabetes?	1	2	3	4	5

Perceived Benefits
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H7. Sticking to my diabetes medication will help prevent diseases (complications) related to diabetes.	1	2	3	4	5
H8. Sticking to my diabetes medication will help me control my diabetes.	1	2	3	4	5
H9. Sticking to my diabetes medication will help me feel better.	1	2	3	4	5
H10. Sticking to my diabetes medication will help me live longer.	1	2	3	4	5

Perceived Barriers
	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
H11. I have difficulty remembering when to take my diabetes medication.	1	2	3	4	5
H12.Family problems make it difficult for me to take my diabetes medication regularly.	1	2	3	4	5
H13. I would have to change too many habits to take my diabetes medication regularly.	1	2	3	4	5
H14. Taking my diabetes medication interferes with my normal daily activities.	1	2	3	4	5
H15. I don’t feel motivated to take my diabetes medication regularly.	1	2	3	4	5

H16. Morisky Medication Adherence (SELF MANAGEMENT BEHAVIOR)

	Yes	No
A. Do you ever forget to take your diabetes medicine?	1	0
B. Are you always careful about taking your diabetes medicine?	1	0
C. When you feel better do you sometimes stop taking your diabetes medicine?	1	0
D. Sometimes if you feel worse when you take the diabetes medicine, do you stop taking it?	1	0

H17. During the past 6 months, did you start using insulin?

H17A. If yes, do you know the name of your insulin? _____________________________________________

	Once a Day in the Morning	Once a Day in the Evening	Twice a Day	Three Times a Day	Four or More Times a Day	I use an Infusion Pump
H18. How many times during the day do you usually take your insulin?	1	2	3	4	5	6

H19. How old were you when you started taking insulin?                                                   years

H20. Have you taken insulin for as long as you have had diabetes?

Yes	1
No	0

1. SELF-MANAGEMENT (from Summary of Diabetes Self-Care Activities Measure)

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.

	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days
I1. How many of the last seven days have you followed a healthful eating plan?	0	1	2	3	4	5	6	7
I2.On average, over the past month, how many days per week have you followed your eating plan?	0	1	2	3	4	5	6	7
I3. On how many of the last seven days did you eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
I4. On how many of the last seven days did you eat high fat foods such as red meat or full-fat dairy products?	0	1	2	3	4	5	6	7
I5. On how many of the last seven days did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking)	0	1	2	3	4	5	6	7
I6. On how many of the last seven days did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
I7. On how many of the last seven days did you test your blood sugar?	0	1	2	3	4	5	6	7
I8. On how many of the last seven days did you test your blood sugar the number of times recommended by your health provider?	0	1	2	3	4	5	6	7
I9. On how many of the last seven days did you check your feet?	0	1	2	3	4	5	6	7
I10. On how many of the last seven days did you inspect the inside of your shoes?	0	1	2	3	4	5	6	7

J. The next few questions are about the money you may have spent to improve your diabetes control during the last 6 months. Please answer yes or no to whether you have bought any of the following during the study.

	Yes	No	Estimated cost
J1. Weight loss program (Weight Watchers, Jenny Craig, Optifast, Nutrasystem, Overeater’s Anonymous, etc.)	1	0	J1A
J2. Vitamins, diet pills, supplements	1	0	J2A
J3. Cookbooks	1	0	J3A
J4. Cooking videos	1	0	J4A
J5. Blender	1	0	J5A
J6. Microwave	1	0	J6A
J7. Steamer	1	0	J7A
J8. Pots and pans for low fat cooking	1	0	J8A
J9. Mixer or food processor	1	0	J9A
J10. Food scale	1	0	J10A
J11. Freezer	1	0	J11A
J12. Wok or electric grill	1	0	J12A
J13. Other food related items (please specify):	1	0	J13A

	Yes	No	Estimated cost
J14. Bicycle	1	0	J14A
J15. Exercise videos (Wii fit, Tae Bo, P90X, etc.)	1	0	J15A
J16. Free weights, dumbbells, hand & ankle weights	1	0	J16A
J17. Home gym	1	0	J17A
J18. Stationary bicycle	1	0	J18A
J19. Rowing or skiing machine, stair stepper	1	0	J19A
J20. Treadmill	1	0	J20A
J21. Sport or water aerobics equipment (basketball, volleyball, tennis racket, etc.)	1	0	J21A
J22. Health or gym club membership	1	0	J22A
J23. Exercise, aerobic, yoga, or dance class	1	0	J23A
J24. Personal trainer	1	0	J24A
J25. Exercise sneakers	1	0	J25A
J26. Exercise clothing (socks, underwear, special shoes, etc.)	1	0	J26A
J27. Other fitness related items (please specify):	1	0	J27A

	Yes	No	Estimated cost
J28. Is there anything else you bought to help you control your diabetes that we haven’t already mentioned? Please specify:	1	0	J28A

Now I have some additional questions.

J29. In the past 6 months, how much extra money did you spend on average per week for diabetes friendly foods or extra fruits and vegetables?

_____________________

1. J30. In the last 6 months, how much in total have you paid for your diabetes prescriptions (pills, insulin, etc.)?

_____________________

2. J31. In the last 6 months, how much money have you paid for diabetic supplies (strips, lancets, Glucometers, etc.)?

_____________________

3. J32. In the past 6 months, how much money have you spent on special clothing for exercise (athletic clothing, supportive underwear, special shoes like cleats)?

4. J33. In a normal week, how many hours do you yourself spend shopping for and preparing food for yourself?

_____________________

5. J34. In a normal week, how many hours do your spouse, family, and friends spend shopping and preparing food for you?

6. J35, How much time does it take you to travel to your Improving Diabetic Outcomes (IDO research study) visit?

_____________________

7. J36. Did you visit any of the following doctors/healthcare providers during the study?

	Yes	No	# of visits	Copay
J36A. Primary care provider	1	0	J36A1	J36A2
J36B. Nurse practitioner	1	0	J36B1	J36B2
J36C. Endocrinologist	1	0	J36C1	J36C2
J36D. Cardiologist	1	0	J36D1	J36D2
J36E. Ophthalmologist	1	0	J36E1	J36E2
J36F. Podiatrist	1	0	J36F1	J36F2
J36G. Dentist	1	0	J36G1	J36G2

	Yes	No	# of visits	Copay
J36H. Did you have to visit the emergency room during the last 6 months?	1	0	J36H1	J36H2
If yes, why were you admitted?	J36H3
J36I. Did you have to stay overnight in the hospital during the last 6 months?	1	0	J36I1	J36I2
If yes, why were you admitted?	J36I3
J36J. Did you have any surgeries during the past 6 months?	1	0	J36J1	J36J2
If yes, what was the surgery?	J36J3

End - 18 Month Survey

ID #_________