摘要:美国斯坦福大学留学生调查问卷样本:由美国斯坦福大学医学院留学生设计的糖尿病问卷调查(SAMPLE QUESTIONNAIRE of DIABETES),由斯坦福大学病人教育研究中心提供资料。
美国斯坦福大学留学生调查问卷样本Stanford Patient
Education Research Center
Stanford University School of Medicine
SAMPLE QUESTIONNAIRE of DIABETES
You may use all or parts of the questionnaire at no charge without permission
Stanford Patient Education Research Center
1000 Welch Road, Suite 204
Palo Alto CA 94304
(650) 723-7935 voice • (650) 725-9422 fax
https://patienteducation.stanford.edu
self-management@stanford.edu
Name: Today's date:
Address:
City, state, zip:
Telephone: home ( ) - __ Date of birth:
work ( ) - Sex: Female Male
Background
1. Ethnic origin (check only one):
White not Hispanic Asian or Pacific Islander
Black not Hispanic Filipino
Hispanic American Indian/Alaskan Native
Other: __________________________
2. Please circle the highest year of school completed:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23+
(primary) (high school) (college/university) (graduate school)
3. Are you currently (check only one):
married separated widowed
single divorced
4. Please indicate below which chronic condition(s) you have:
Diabetes type 2 Diabetes type 1 High cholesterol High blood pressure
Heart disease Type of heart disease:
Lung disease Type of lung disease:
Other chronic condition Specify: 2
General Health
1. In general, would you say your health is:
(Circle one)
Excellent...............................1
Very good..............................2
Good......................................3
Fair........................................4
Poor.......................................5
Symptoms
How much time during the past month...
None A little Some A good Most All
of the of the of the bit of the of the of the
time time time time time time
1. Were you discouraged by your
health problems?.....................................0 1 2 3 4 5
2. Were you fearful about your
future health?..........................................0 1 2 3 4 5
3. Was your health a worry in your life?....0 1 2 3 4 5
4. Were you frustrated by your
health problems?.....................................0 1 2 3 4 5
5. We are interested in learning whether or not you are affected by fatigue. Please circle the number below that describes your fatigue in the past 2 weeks:
0 1 2 3 4 5 6 7 8 9 10 No Severe fatigue fatigue 3
6. We are interested in learning whether or not you are affected by pain. Please circle the number below that describes your pain in the past 2 weeks.
0 1 2 3 4 5 6 7 8 9 10 No Severe pain pain
7. We are interested in learning whether or not you are affected by shortness of breath. Please circle the number below that describes your shortness of breath in the past 2 weeks:
0 1 2 3 4 5 6 7 8 9 10 No Severe shortness shortness of breath of breath
In the PAST WEEK, did you ever have any of the following symptoms…
8. Increased thirst? ................................................................................ No Yes Don’t know
9. Dry mouth?........................................................................................ No Yes Don’t know
10. Decreased appetite? ...........
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