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DEMOGRAPHICS
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1.
Gender
Male
Female
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2.
Which bests describes your ethnicity?
Asian
Native
American
Hispanic/Latino
Other
Caucasian/White
African
American/Black
Acadian |
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3.
Age
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4.
Education (Please select highest attained)
High
School
Some
College
Completed
Community College |
Diploma
Bachelors
Degree
Masters
Degree
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PhD
Other
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If you completed college or university please indicate your
diploma/degree
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5.
How long have you worked as part of a diabetes education centre?
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Less
than 2years
2 years
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4 years
6 years
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8 years
10 years or more
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6.
On average, how many clients do work with per day?
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Less than 5 clients
5 to 10 clients
10 to 15 clients
15 to 20 clients
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20 to 25 clients
25 to 30 clients
More than 30 clients
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7.
On average, how long do you spend with each client?
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Less that 10 minutes
10 – 20 minutes
20 – 30 minutes
30 – 40 minutes
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40 – 50 minutes
50 – 60 minutes
More than 1 hour
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8.
Have you received any formal training in instruction or
counseling of physical activity and exercise? If so, in what form?
(Please check all that apply)
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Workshops
Professional Development
As a part of your degree
Conference presentations
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National certification
Provincial certification
Other
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9.
In what percentage of counseling sessions do you include physical
activity and exercise content?
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100-75%
75-50%
50-25%
25-10%
less than 10%
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10.
In the sessions in which you discuss physical activity, on
average, what percentage of the session is spent on this topic?
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100-75%
75-50%
50-25%
25-10%
less than 10%
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Diabetes Educators
Physicians
Nurses
Dietitians
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Kinesiologists (degree)
Personal Trainers (certificate)
Other
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CONFIDENCE
Using the space provided,
please circle the option for each question below that best reflects
how confident you are in your ability to perform the following
actions in the next month:
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1.
Provide information and advice regarding the benefits of physical
activity and exercise?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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2.
Evaluate and monitor the progress of your clients within an
exercise program?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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3.
Design a physical activity or exercise program that accommodates
clients’ individual needs or limitations?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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4.
Assess clients’ readiness/willingness to begin regular physical
activity or exercise?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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5.
Assist clients in setting appropriate, realistic and beneficial
goals?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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6.
Motivate clients to participate in exercise and physically active
behaviors?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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7.
Provide advice and instruction regarding aerobic exercise?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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8.
Provide advice and instruction regarding resistance training?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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9.
Provide advice and instruction regarding flexibility (range of
motion) exercises?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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10.
Provide advice and instruction regarding appropriate frequency,
intensity, time or type of physical activity and exercise?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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11.
Provide clients with strategies to overcome barriers to physical
activity or exercise?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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12.
Provide instruction regarding physical activity and exercise to
clients with special considerations (e.g. hypertension, elevated CVD
risk, musculo-skeletal or mobility problems, cognitive problems)?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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13.
Assist clients in preventing lapses in their physical activity
and exercise participation?
0%
10%
20% 30%
40%
50%
60% 70%
80%
90% 100%
Not at all confident
Somewhat confident
Completely confident
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ATTITUDES
We are interested in your
attitudes regarding physical activity and exercise in the management of
diabetes. Using the space provided, please select the answer that
best describes your feelings toward these questions.
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1.
How important do you feel physical activity and exercise is in
the self-management of diabetes?
1
2
3
4
5
Not at all
Somewhat
Extremely
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2.
How receptive would you be
to an increased focus on physical activity during sessions with clients?
1
2
3
4
5
Not at all
Somewhat
Extremely
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3.
How important do you feel your clients think physical
activity and exercise are in the self-management of diabetes?
1
2
3
4
5
Not at all
Somewhat
Extremely
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4.
How knowledgeable do you feel you are in the area of physical
activity and exercise?
1
2
3
4
5
Not at all
Somewhat
Extremely
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5.
How receptive do you think your client base would be
to an increased focus on physical activity during their sessions?
1
2
3
4
5
Not at all
Somewhat
Extremely
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6.
How knowledgeable do you feel your clients are in
the area of physical activity and exercise?
1
2
3
4
5
Not at all
Somewhat
Extremely
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CONFIDENCE IN CLIENT
Considering your typical client, please circle the option for each
question below that best reflects how confident you are in your
typical client’s ability to perform the following behaviors over the
next month:
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1.
Appropriately schedule exercise and physically active behaviors
into their weekly routine?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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2.
Set and work toward realistic and beneficial goals?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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3.
Return to exercise and physically active behaviors following a
lapse in their exercise routine?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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4.
Perform exercise and physically active behaviors appropriate for
their fitness level and condition?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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5.
Perform physical activity and exercise using the correct mode,
frequency, duration, and intensity?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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6.
Overcome challenges and barriers they
may face that prevent participation in or adherence to a physical
activity or exercise program?
0% 10% 20% 30%
40%
50%
60% 70%
80%
90%
100%
Not at all confident
Somewhat confident
Completely confident
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PERCEIVED DIFFICULTY
Please select the answer that best describes your feelings of
how difficult it would be
to incorporate each of these amounts of time into counseling sessions
over the next month.
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1.
How difficult do you feel it would be to include information on
how to perform physical activity & exercise into sessions with
clients?
1
2
3
4
5
Very difficult
Somewhat difficult
Not at all difficult
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2.
How difficult do you feel it would be to include counseling
on
how to perform physical activity & exercise into sessions with
clients?
1
2
3
4
5
Very difficult
Somewhat difficult
Not at all difficult
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3.
How difficult do you feel it would be to include instruction on
how to perform physical activity & exercise into sessions with
clients?
1
2
3
4
5
Very difficult
Somewhat difficult
Not at all difficult
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4.
How difficult do you feel it would be to include all of these
components (information, counseling and instruction on how to perform
physical activity & exercise) in sessions with clients?
1
2
3
4
5
Very difficult
Somewhat difficult
Not at all difficult
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CHALLENGES
Using
the spaces provided please tell us about any challenges (up to 3) you
face in regard to incorporating more physical activity and exercise
counseling into diabetes patients management. For each barrier listed,
please use the scales provided to indicate how frequently they occur and
how difficult they make exercise counseling when they do occur.
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Frequency
1 = Rarely occurs
2 =
Occurs Infrequently
3 = Occurs Frequently
4 = Constant barrier
Impact
1 = Does not prevent me from including physical activity and exercise
counseling
2 = Sometimes prevents me from including physical activity and exercise
counseling
3 = often prevents me from including physical activity and exercise
counseling
4 = Completely prevents me from including physical activity and exercise
counseling
Barrier
Frequency
Impact
a)
-
1 2 3
- 1 2 3
b)
-
1 2 3
- 1 2 3
c)
-
1 2 3
- 1 2 3
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THANK YOU
FOR COMPLETING THIS QUESTIONNAIRE!
We appreciate your time and willingness to complete this and the
previous questionnaires!
Your participation is vital to the success of evaluating and
implementing the ‘tool-kit.’
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