Quarterly Provider Follow-Up & Evaluation
1. What is your name?
*
2. What is the name of your practice?
*
3. Since beginning this program, please estimate how many patients have received the "DUO for Health" materials.
*
4. How satisfied are you with "DUO for Health" program materials?
*
Not at all satisfied
Slightly satisfied
Neutral
Very satisfied
Extremely satisfied
How are you using the DUO for Health program materials?
*
Mark
ALL
that Apply
Provided directly by provider to patient during routine office visit
Made available in waiting room for patients to take
Made available in exam room for patients to take
Distributed during health coaching, nutrition therapy, or wellness counseling sessions
Distributed during group classes, such as group diabetes education
Other
5. How interested are your patients in the brochures?
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Not at all interested
Slightly interested
Very interested
Extremely interested
6. How interested are your patients in the recipe cards?
*
Not at all interested
Slightly interested
Very interested
Extremely interested
7. How interested are your patients in the orange peelers?
*
Not at all interested
Slightly interested
Very interested
Extremely interested
8. How could the program materials be improved?
*
9. Please describe any barriers encountered utilizing program materials with your patients?
*
10. Please rate your agreement with this statement: "Program materials have affected the frequency of dietary advice you provide during routine medical visits for patients with diabetes and/or hypertension?"
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
11. Please rate your agreement with this statement: "Program materials have affected your ability to give dietary advice to your patients during clinical visits."
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
12. Please use this space to provide any de-identified success stories of how these materials have helped your patients in making healthy dietary changes
*
13. Do you need to order more health brochures?
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Yes
No
How many health brochures do you need?
14. Do you need to order any Spanish health brochures?
*
Yes
Yes
No
How many Spanish health brochures do you need?
15. Do you need to order more orange peelers?
*
Yes
No
How many orange peelers do you need?
16. Do you need to order more recipe cards?
*
Yes
No
How many recipe cards do you need?
Do you need to order more cooking method cards?
Yes
No
How many cooking method cards do you need?
17. Please use this space to provide any additional feedback to help improve the DUO for Health program.
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