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At your last Dr.'s appointment, how was your health?
 
Poor
 
Average
 
Excellent
 
 
 
Your Dr. was happy with your health?
 
Completely disagree
 
Somewhat disagree
 
Slightly disagree
 
Neutral, Slightly agree
 
Somewhat agree
 
Completely agree
 
 
 
The Dr. is concerned of your health issues?
 
Strongly disagree
 
Somewhat disagree
 
Slightly disagree
 
Neither agree nor disagree
 
Slightly agree
 
Somewhat agree
 
Strongly agree
 
 
 
Are you concerned with your weight?
 
Extremely
 
Very
 
Moderately
 
Slightly
 
Not at all
 
 
 
Are you concerned about Diabetes or any other chronic diseases?
 
Always
 
Most of the time
 
About half the time
 
Once in a while
 
Never
 
 
 
You are happy with the steps your Dr. suggest for better health?
 
Completely unsatisfied
 
Somewhat unsatisfied
 
Neither satisfied nor unsatisfied
 
Somewhat satisfied
 
Completely satisfied
 
 
 
You are happy with how your health is improving?
 
Strongly disagree
 
Somewhat disagree
 
Slightly disagree
 
Neither agree nor disagree
 
Slightly agree
 
Somewhat agree
 
Strongly agree
 
 
 
On average how many days a week are you exercising?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
 
I am setting goals to eat more fruits and vegetables less sugary and high fat foods
 
Strongly disagree
 
Somewhat disagree
 
Neither agree nor disagree
 
Somewhat agree
 
Strongly agree
 
 
 
I am now drinking more water, and less sugary beverages
 
Strongly disagree
 
Somewhat disagree
 
Neither agree nor disagree
 
Somewhat agree
 
Strongly agree
 
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