Never in the past month	Once in the past month	Two or three times in the past month	Once each week	Twice or more each week
How often do your friends or family members…	1	2	3	4	5
1. exercise with you or ask you to exercise with them?	○	○	○	○	○
2. point out in front of others when you are eating unhealthy foods, like at a party or get together?	○	○	○	○	○
3. gently talk with you about taking care of your diabetes?	○	○	○	○	○
4. help you decide if changes should be made based on your blood sugar testing results?	○	○	○	○	○
5. bring foods around that you shouldn’t be eating?	○	○	○	○	○
6. tell you diabetes is your problem to deal with on your own?	○	○	○	○	○
7. ask how they can help you with your diabetes?	○	○	○	○	○
8. suggest things that might help you take your diabetes medicine when you are supposed to?	○	○	○	○	○
9. argue with you about your food choices or your health?	○	○	○	○	○
10. praise you for eating healthy foods or following your exercise routine?	○	○	○	○	○
11. criticize you for not testing your blood sugar?	○	○	○	○	○
12. help you choose healthy foods, by reading food labels or helping you choose from a menu?	○	○	○	○	○
13. criticize you for not exercising?	○	○	○	○	○
14. prepare or plan healthy foods to help with your recommended diet?	○	○	○	○	○
15. suggest you don’t need to take your diabetes medicine?	○	○	○	○	○
16. take on one of your responsibilities, so you can have time to exercise?	○	○	○	○	○