Gravity Forms Copier

I agree to allowing the My Diabetes My Way team to monitor how my diabetes test have changed to assess the effectiveness of this course.
- I agree
- I do not agree
Your healthcare team would like to know that you are undertaking this eLearning course. We would like to inform them that you have undertaken this eLearning course.
- I agree to you letting my health care team know that I have completed this course.
- I do not agree to you letting my health care team know that I have completed this course.
Name*
First Last
Email*
GP Practice*
Home Postcode*

Please confirm which of the following apply to you:
- I am a person with type 1 diabetes
- I am a family member or carer of a person that has diabetes
- I am a healthcare professional
- I am none of the above
Please confirm which of the following apply to you:
- I am a person with type 1 diabetes
- I am a person with type 2 diabetes
- I am a person with gestational diabetes
- I am a person at risk of developing type 2 diabetes
- I am a family member or carer of a person that has diabetes
- I am a healthcare professional
- I am none of the above
On a scale of strongly disagree to strongly agree, please answer the statements below:
Strongly disagree Disagree Neutral Agree Strongly agree
I am satisfied with my life
I know enough about my health
I manage my diabetes well
Goal Setting
What would you like this course to help you achieve?
Some of the things people write about are… eating healthier, giving up smoking, taking better control of blood glucose levels, attending scheduled check-up appointments or increasing physical activity - whatever is appropriate for you.
How important is it for you to reach the goals you have set?
Very unimportant Unimportant Neutral Important Very important
How are you going to reach your goals?
What might stop you from reaching your goals and how can you overcome these barriers?
How confident do you feel in achieving what you would like to?
Very unconfident Unconfident Neutral Confident Very confident
Year of diagnosis
Please click the submit button below

Please confirm which of the following apply to you:
- I am a person with type 1 diabetes
- I am a person with type 2 diabetes
- I am a person with gestational diabetes
- I am a person at risk of developing type 2 diabetes
- I am a family member or carer of a person that has type 2 diabetes
- I am a healthcare professional
- I am none of the above
Please confirm which of the following apply to you:
- I am a person with type 1 diabetes
- I am a family member or carer of a person that has type 2 diabetes
- I am a healthcare professional
- I am none of the above

On a scale of strongly disagree to strongly agree, please answer the statements below:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
The course was useful
The course had all the information I expected
The course was easy to follow
The course helped me to improve my knowledge of treatment of diabetes
The course has helped me to set my own diabetes goals
My learning was enhanced by sharing information with other people with diabetes or listening to their stories

On a scale of strongly disagree to stronly agree, please answer the statements below:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
The course has motivated me around managing my diabetes
The course has improved my confidence around managing my diabetes
I will make a change to the way I manage my diabetes as a result of this course
The course has improved my overall health and wellbeing
I am satisfied with my life
I know enough about my health
I manage my diabetes (or risk of diabetes) well

Is there anything that you found particularly enjoyable or useful in this course?
Is there anything you would like to see improved on this course?
Any other feedback?
Please click the submit button below

Please confirm which of the following apply to you:
- I am a person with type 1 diabetes
- I am a family member or carer of a person that has type 1 diabetes
- I am a healthcare professional
- Other
On a scale of strongly disagree to strongly agree, please answer the statements below:
Strongly disagree Disagree Neutral Agree Strongly agree
I am satisfied with my life
I know enough about my health
I manage my diabetes well
What would you like this course to help you achieve?
Some of the things people write about are… eating healthier, giving up smoking, taking better control of blood glucose levels, attending scheduled check up appointments or increasing physical activity.
How important is it for you to reach the goals you have set?
Very unimportant Unimportant Neutral Important Very important
How are you going to reach your goals?
What might stop you from reaching your goals and how can you overcome these barriers?
How confident do you feel in achieving what you would like to?
Very unconfident Unconfident Neutral Confident Very confident
Year of diagnosis?
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Please click the submit button below

Goal Setting