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Mindful Diabetes Care Feedback Form
School Name
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Grade Level
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Country
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Compared with before the presentation, how is your understanding of diabetes now?
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I understand very well.
I understand better now.
I understand a little.
I am still not sure.
Compared with before the presentation, how is your understanding of the everyday challenges faced by people with diabetes?
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Much better
A little better
About the same
Less clear
Which statement about pre-diabetes is correct?
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A person can have pre-diabetes without noticing any symptoms
Pre-diabetes is the same as Type 1 diabetes
Pre-diabetes always causes noticeable symptoms
I am not sure
How useful was this presentation?
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Very useful
Somewhat useful
A little useful
Not useful
Diabetes Awareness Pledge: Choose one action you would like to try during the next 30 days:
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Do an activity I enjoy for at least 20 minutes on three days
Take short movement breaks during long study or screen time
Choose a balanced meal or snack at least three times
Share one accurate diabetes fact with someone
Learn one more diabetes fact from a reliable source
I do not want to make a pledge today
Are you likely to share something you learned today with another person?
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Yes
No
Would you be willing to complete a one-minute follow-up survey in approximately three months?
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Yes
No
OPTIONAL TESTIMONIAL What did you find most helpful or meaningful about today’s presentation? Please do not include your name, personal health information or anyone else’s private information.
Mindful Diabetes Pledge : I pledge to learn about diabetes and make healthier choices.
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Yes, I pledge.
Submit
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