SAMPLE QUESTIONNAIRE Patient Education （样本问卷调查患者教育）.pdf

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2017-09-02 发布于浙江
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SAMPLE QUESTIONNAIRE Patient Education （样本问卷调查患者教育）.pdf

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SAMPLE QUESTIONNAIRE Patient Education （样本问卷调查患者教育）

Stanford Patient Education Research Center Stanf ord University School of Medicine SAMPLE QUESTIONNAIRE 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 self-management@ Name: Todays 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+ (p rimary) (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: