Name:

E-mail:

1. Did you complete all the Focus on Diabetes modules (lessons)? Yes No
2. If you did not do all of them, which ones did you complete?
   What is Diabetes?
   Diabetes Management
   Healthy Eating
   Physical Activity
   Diabetes Medication
   High and Low Blood Glucose
   Monitoring Diabetes
   Diabetes Complications
   Coping with Diabetes
3. How will you use the information from Focus on Diabetes? (Check all that apply)
   I will make changes in my eating habits.
   I will become more physically active.
   I will talk to my health care provider about my diabetes medicines.
   I will use my blood glucose results to adjust my diabetes medicines, food intake or activity level.
   I will start carrying glucose tablets, glucose gel or a recommended snack to prevent low blood glucose.
   I will begin checking my feet every day.
   I will drink less alcohol.
   I will get my blood pressure under control.
   I will quit smoking.
   I will join a diabetes support group.
   I will tell my family how they can help me with my diabetes.
   I don't have diabetes, but I will share this information with someone who does.
4. How would you rate the delivery of Focus on Diabetes in this format?
   I like it very much.
   I liked it somewhat.
   I neither liked or disliked it.
   I disliked it somewhat.
   I did not like it at all.
5. Would you recommend Focus on Diabetes to others?
   Yes
   No
6. How did you learn about Focus on Diabetes?
   From my Extension Office
   From an on-line computer search
   From my health care provider
   From family or friend
   From TV, radio, newspaper or newsletter
   Other, please explain -
7. How could Focus on Diabetes be improved?
   
8. Other comments?