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.

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?

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?"

11. Please rate your agreement with this statement: "Program materials have affected your ability to give dietary advice to your patients during clinical visits."

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?

Yes

14. Do you need to order any Spanish health brochures?

Yes

15. Do you need to order more orange peelers?

Yes

16. Do you need to order more recipe cards?

Yes

Do you need to order more cooking method cards?

Yes

17. Please use this space to provide any additional feedback to help improve the DUO for Health program.

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