ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

ISLL/Patient/Wave 2/Time 1

Patient Identification Number:______

DateofConsent:______

(For office use only)

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

INSTRUCTIONS TO HEALTH COACH: Please ask the following questions as they are written. Do not read the names of the different scales/questionnaires. Anything you should not read out is in RED FONT.

Patient MedicationAdherenceQuestions

SECTION A. I am going to ask you some questions to help us better understand your health and to help me prepare better for our health coaching sessions. This should take about 20 to 30 minutes. These first questions are about taking medications.

  1. Are you on insulin?(If YES, continue with this section. If NO, skip to Section B)

Yes

No

Manypatients have told methat they finditdifficult totake alloftheir insulinexactly asthe doctor prescribed.I want toget anidea ofhowharditis foryou.

  1. Doyousometimesforget totakeyourinsulin?

Yes

No

  1. Overthe past2 weeks werethere anydayswhenyoudidnot takeyourinsulin?

Yes

No

  1. Have youevercut backorstoppedtakingyour insulinwithout tellingyour doctorbecause youfelt worse when youtook it?

Yes

No

  1. Whenyoutravelor leavehome, doyousometimes forgettobringalongyour insulin?

Yes

No

  1. Didyoutake your insulinyesterday?

Yes

No

  1. Whenyoufeel likeyourdiabetesis under control, doyousometimesstoptakingyour insulin?

Yes

No

  1. Takinginsulineveryday isa real inconvenienceforsomepeople.Doyouever feel hassledabout sticking toyourdiabetesmanagement plan?

Yes

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

No

  1. Howoften do youhave difficultyrememberingtotakeall your insulin?

Noneofthe time

A little ofthetime

Someofthe time

Mostofthe time

All ofthetime

SECTION B: Manypatients have told me that they finditdifficult totake alloftheirmedicationsexactlyasthe doctor prescribed.I want toget anidea ofhowharditis for you.

10. Doyousometimesforget totakeyourmedicine?

Yes

No

  1. Overthe past2 weeks were there anydayswhenyoudidnot takeyourmedicine?

Yes

No

  1. Haveyouever cut backorstopped takingyourmedicationwithouttellingyour doctor becauseyoufelt worse when youtook it?

Yes

No

  1. Whenyoutravelorleave home, doyousometimesforget tobringalongyourmedications?

Yes

No

  1. Didyoutakeyourmedicineyesterday?

Yes

No

  1. Whenyoufeel like your diabetesisunder control, doyousometimesstoptakingyourmedications?

Yes

No

  1. Taking medicationevery day is areal inconveniencefor somepeople. Doyouever feel hassled about stickingtoyour diabetesmanagement plan?

Yes

No

  1. Howoften do youhave difficultyrememberingtotakeall your diabetesmedication?

Noneofthe time

A little ofthetime

Someofthe time

Mostofthe time

All ofthetime

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ISLL/Patient/Wave 1/Time 1Patient Identification Number: ______

Patient Generalized Anxiety Questions (GAD-7)

Now I am going to ask you some questions about how you feel. Can you please pull out the GREEN sheet of paper in your packet.I will read out the questions—please choose from one of the responses on the green sheet. Okay, are you ready? Over the last two weeks, how often have you been bothered by the following problems?

Not at all / Several days / More than half the days / Nearly every day
  1. Feeling nervous, anxious or on edge
/ 0 / 1 / 2 / 3
  1. Not being able to stop or control worrying
/ 0 / 1 / 2 / 3
  1. Worrying too much about different things
/ 0 / 1 / 2 / 3
  1. Trouble relaxing
/ 0 / 1 / 2 / 3
  1. Being so restless that it is hard to sit still
/ 0 / 1 / 2 / 3
  1. Becoming easily annoyed or irritable
/ 0 / 1 / 2 / 3
  1. Feeling afraid as if something awful might happen
/ 0 / 1 / 2 / 3

(Circle the patient’s responses)

(For office coding: Total Score T______= ______+ ______+ ______)

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

Patient Self-EfficacyforDiabetesQuestions

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

Now I am going to ask you some questions about how confident you feel about doing certain activities. Can you please pull out the ORANGE sheet from your packet. For eachof thefollowing questions, pleasechoosethenumberthat corresponds to your confidencethatyoucando thetasks regularly at the present time from the orange sheet. Okay, are you ready?

(Circle the patient’s responses)

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

25.Howconfidentdoyoufeelthatyoucan eatyourmeals every4to5hours every day, includingbreakfast every day? / notatall |||||||||| totally confident 123456 7 8 9 10confident
26.Howconfidentdoyoufeelthatyoucan followyourdietwhenyouhaveto prepareorsharefoodwithother people whodonothavediabetes? /
notatall |||||||||| totally confident 123456 7 8 9 10confident
27. Howconfidentdoyoufeelthatyoucan choosetheappropriatefoodstoeat whenyouarehungry(forexample, snacks)? / notatall |||||||||| totally confident 123456 7 8 9 10confident
28. Howconfidentdoyoufeelthatyoucan exercise15to30minutes,4to5timesa week? / notatall |||||||||| totally confident 1234 5 6 7 8 9 10confident
29. Howconfidentdoyoufeelthatyou candosomethingtopreventyour bloodsugar levelfrom dropping whenyou exercise? / notatall |||||||||| totally confident 123456 7 8 9 10confident
30. Howconfidentdoyoufeelthatyou
knowwhattodowhenyourbloodsugar levelgoeshigheror lower thanitshould be? / notatall |||||||||| totally confident 123456 7 8 9 10confident
31.Howconfidentdoyoufeelthatyoucan judgewhenthechangesinyourillness meanyoushouldvisitthedoctor? / notatall |||||||||| totally confident 123456 7 8 9 10confident
32. Howconfidentdoyoufeelthatyoucan controlyour diabetes sothatitdoesnot interfere with thethings you wantto do? / notatall |||||||||| totally confident 123456 7 8 9 10confident

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

Patient Depression Questions (PHQ-9)

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

Now I am going to ask you some questions about your recent mood. Can you please pull out the BLUE sheet of paper in your packet. I will read out the questions—please choose from one of the responses on your blue sheet. Okay, are you ready?Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Circle the patient’s responses)

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ISLL/Patient/Wave 1/Time 1Patient Identification Number:______

Not at all / Several days / More than half the days / Nearly every day
  1. Little interest or pleasure in doing things
/ 0 / 1 / 2 / 3
34. Feeling down, depressed, or hopeless / 0 / 1 / 2 / 3
  1. Trouble falling or staying asleep, or sleeping too much
/ 0 / 1 / 2 / 3
  1. Feeling tired or having little energy
/ 0 / 1 / 2 / 3
  1. Poor appetite or overeating
/ 0 / 1 / 2 / 3
  1. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
/ 0 / 1 / 2 / 3
  1. Trouble concentrating on things, such as reading the newspaper or watching television
/ 0 / 1 / 2 / 3
  1. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
/ 0 / 1 / 2 / 3
  1. Thoughts that you would be better off dead, or of hurting yourself
/ 0 / 1 / 2 / 3

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ISLL/Patient/Wave 1/Time 1 Patient Identification Number:______

ISLLPatient DemographicQuestions

These are the last set of questions and should only take another 2 to 3 minutes.

Health coach, please answer this question yourself before proceeding:

  1. Is your Faculty Supervisor present at this first meeting?

Yes

No

For the following questions please select ONE response:

  1. What is your biological sex?

Female

Male

  1. What is your age?___yrs.
  1. What isyourethnicorigin?

Non-Hispanic

Hispanic

Latino

Spanish

  1. What isyourracial background?

Caucasian/White

AfricanAmerican/Black

Asian

  1. Are you:

Single

Married/livingwith someone

Divorced/Widowed

  1. Howmanychildren doyouhave?(If NONE,skipto50)
  1. Howmanyofyour childrenliveat home?(If NONE, skipto50)
  1. Howmany total peoplelivein your householdincludingyourself,yourchildren andany other familymembers?__
  1. What isthe highestgrade or yearofschoolyouhave completed?

8thgradeor less

Some highschool

Graduatedfromhighschool

Graduatedfromtechnicalschool

Bachelor’sDegree (4 years)

GraduateDegree

GED

None/noanswer

  1. Are youcurrentlyworkingfor pay?

No

Yes, full-time

Yes,part-time

  1. Please stopmewhen Icome toyour total combinedyearlyhouseholdincome beforetaxes. (This is for statistical purposesonlyandwill not be linked withyourname inanyway)

$20,000orless

$20,001- $40,000

$40,001- $60,000

$60,001- $80,000

$80,001- $100,000

$100,001 andabove

Noanswer

**Health coach, please be sure to use the closing prompt on page 9**

I want to thank you for taking the time to answer these questions. I would like to set up some times when I can call you for our health coaching.

HEALTH COACH, Continue on with asking about best days and times and set up at least the next 3 calls.

Please hand this completed packet to the promotora before you leave.

-- End of Time 1 Questionnaire --

**Note: Health Coach, on the following page are resources for the health coaching questionnaire. These are for your reference ONLY.

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Scoring

FOR USE BY HEALTH COACH. DO NOT READ FROM HERE ON.

Reference Materials

Patient Self-Efficacy Questions

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Thescoreforeach itemisthenumbercircled.Iftwo consecutive numbersarecircled,codethe lower number(lessself-efficacy).Ifthe numbersare notconsecutive,donotscorethe item.Thescoreforthe scale is themean ofthesix items.Ifmorethantwo itemsaremissing,donotscorethescale.Higher numberindicateshigherself-efficacy.

Characteristics

Tested on186subjectswith diabetes.

.

No.of items / Observed Range / Mean / Standard Deviation / Internal Consistency Reliability / Test-Retest Reliability
8 / 1-10 / 6.87 / 1.76 / .828 / NA

Source ofPsychometricData

StanfordEnglish DiabetesSelf-Managementstudy.Studyreported inLorig K,Ritter PL, Villa FJ,Armas

J.Community-BasedPeer-Led DiabetesSelf-Management:ARandomizedTrial.The Diabetes Educator2009;Jul-Aug;35(4):641-51.

Comments

This8-itemscale was originallydeveloped and tested in Spanishforthe DiabetesSelf-Management study.For internetstudies,we addradio buttonsbeloweach number.There is anotherwaythatwe use toformatthese items,which takesup lessspaceon aquestionnaire,shown also in the PDF document. Thisscale is available in Spanish.

References

Unpublished.

Thisscale isfreetousewithoutpermission

StanfordPatient EducationResearch Center

1000Welch Road,Suite204 Palo Alto CA94304

(650)723-7935

(650)725-9422Fax

ttp://patienteducation.stanford.edu

Funded bytheNationalInstituteofNursing Research(NINR)

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PHQ-9PatientDepressionQuestions Score Card

Forinitialdiagnosis:

1.Patient completes PHQ-9 QuickDepressionAssessment.

2. Ifthereareatleast 4circles inthe shaded section(includingQuestions#33and#34),consideradepressive disorder. Add score todetermine severity.

ConsiderMajorDepressiveDisorder

-ifthereare atleast 5circlesin theshaded section(oneofwhich corresponds toQuestion#33or#34)

ConsiderOtherDepressiveDisorder

-ifthereare2-4circlesintheshadedsection (one ofwhichcorrespondstoQuestion#33or #34)

Note:Since the questionnairerelies onpatientself-report, allresponses shouldbeverifiedby the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant informationfrom thepatient.

DiagnosesofMajorDepressive DisorderorOtherDepressive Disorder alsorequire impairmentof social, occupational, orother importantareas offunctioning(Question#41) and ruling outnormalbereavement, a historyof a Manic Episode(BipolarDisorder), and a physicaldisorder,medication, orotherdrugas thebiologicalcause of thedepressive symptoms.

To monitor severity overtime for newly diagnosed patients or patients in current treatment for depression:

1.Patients may complete questionnaires at baseline andatregular intervals (eg, every 2 weeks) at home and bring themin at their next appointment for scoring or they may complete the questionnaireduring each scheduledappointment.

2.Addupcirclesbycolumn. For everycircle: Severaldays=1Morethanhalf thedays=2 Nearlyeveryday=3

3.Add togethercolumnscores togeta TOTAL score.

4.Refer totheaccompanyingPHQ-9Scoring Box to interpret the TOTALscore.

5. Results may be included in patient files to assist youin setting up a treatment goal,determiningdegreeof response, aswell as guidingtreatment intervention.

Scoring:addupall circledboxesonPHQ-9 For everycircle:Notatall=0;Severaldays=1;

More than half the days = 2; Nearly every day = 3

Interpretation of Total Score

Total Score / DepressionSeverity
1-4 / Minimaldepression
5-9 / Milddepression
10-14 / Moderatedepression
15-19 / Moderatelyseveredepression
20-27 / Severedepression

PHQ9 Copyright ©Pfizer Inc.All rightsreserved.Reproducedwithpermission. PRIME-MD® is a trademark ofPfizerInc.

A2662B10-04-2005

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