CC-SCODI (English)
Authored By
Davide Ausili, RN, MSc, PhD
Assistant Professor
Università degliStudi di Milano –Bicocca,
Via Cadore 48, Monza –Italy
Phone: +390264488032
Email: davide.ausili@unimib.it
Dr. Barbara Riegel, PhD, RN, FAHA, FAAN
Professor
Caregiver
Contribution to Self-Care of Diabetes Inventory (CC-SCODI)
Please think about what you did in the last month.
SECTION A
Below are listed some behaviors that
a person with diabetes could perform to maintain health and wellness. How often
do you recommend the following
things to the person you care for? (Or, how often do you do these activities because the person you care for is not able to
do them?).
(circle one number)
|
|
NEVER |
|
|
|
ALWAYS |
1. |
Maintain an active life-style (example: walking,
going out, doing activities)? |
1 |
2 |
3 |
4 |
5 |
2. |
Perform physical exercise for 2 hours and 30 minutes
each week? (example: swimming, going to the gym, cycling, walking) |
1 |
2 |
3 |
4 |
5 |
3. |
Eat a balanced diet of carbohydrates
(pasta, rice, sugars, bread), proteins (meat, fish, legumes), fruits
and vegetables? |
1 |
2 |
3 |
4 |
5 |
4. |
Avoid eating salt and fats (example: cheese, cured
meats, sweets, red meat)? |
1 |
2 |
3 |
4 |
5 |
5. |
Limit alcohol intake (no more than 1 glass of
wine/day for women and 2 glasses/day for men)? |
1 |
2 |
3 |
4 |
5 |
6. |
Try to avoid getting sick (example: wash your hands, get recommended
vaccinations)? |
1 |
2 |
3 |
4 |
5 |
7. |
Avoid cigarettes and tobacco smoke? |
1 |
2 |
3 |
4 |
5 |
8. |
Take care of your feet (wash and dry the skin, apply
moisture, use correct socks)? |
1 |
2 |
3 |
4 |
5 |
9. |
Maintain good oral hygiene (brush your teeth at
least twice/day, use mouthwash, use dental floss)? |
1 |
2 |
3 |
4 |
5 |
10. |
Keep appointments with your health care provider? |
1 |
2 |
3 |
4 |
5 |
11. |
Have your health check-ups on time? (example: blood
tests, urine tests, ultrasounds, eye exams)? |
1 |
2 |
3 |
4 |
5 |
12. |
Many
people have problems taking all their prescribed medicines. Do you take all your medicines as prescribed (please
also consider insulin if your doctor prescribed it for you)? |
1 |
2 |
3 |
4 |
5 |
SECTION B
Below are some behaviors that a
person with diabetes could practice to monitor their diabetes. How often do you
recommend the following things to
the person you care for? (Or, how often do you do these activities because the person you care for is not able to
do them?).
(circle one number)
|
|
NEVER |
|
|
|
ALWAYS |
13. |
Monitor blood sugar regularly? |
1 |
2 |
3 |
4 |
5 |
14. |
Monitor weight? |
1 |
2 |
3 |
4 |
5 |
15. |
Monitor blood pressure? |
1 |
2 |
3 |
4 |
5 |
16. |
Keep a record of blood sugars in a diary or notebook? |
1 |
2 |
3 |
4 |
5 |
17. |
Monitor the condition of feet daily to see if there
are wounds, redness or blisters? |
1 |
2 |
3 |
4 |
5 |
18. |
Pay attention to symptoms of high blood sugar
(thirst, frequent urination) and low blood sugar (weakness,
perspiration, anxiety)? |
1 |
2 |
3 |
4 |
5 |
The last time the person you care for had symptoms:
|
|
I DIDN’T RECOGNIZE SYMPTOMS |
NOT QUICKLY |
|
|
|
VERY QUICKLY |
19. |
How quickly did you
recognize that he or she was having symptoms? |
0 |
1 |
2 |
3 |
4 |
5 |
20.
|
How quickly did you
know that the symptoms were due to diabetes? |
0 |
1 |
2 |
3 |
4 |
5 |
SECTION C
Below are listed some
behaviors a person with diabetes could do to improve their blood sugar when
it’s too high or too low.
How often do you recommend the following things to the person you care for? (Or, how
often do you do these activities
because the person you care for is not able to do them?).
(circle one number)
|
|
NEVER |
|
|
|
ALWAYS |
21. |
To check blood sugar when the person you care for feels
symptoms (such as thirst, frequent urination, weakness, perspiration,
anxiety). |
1 |
2 |
3 |
4 |
5 |
22. |
When the person you care for has abnormal blood
sugar levels, to take notes about the events that could have caused it and
actions he or she took. |
1 |
2 |
3 |
4 |
5 |
23. |
When the person you care for has abnormal blood
sugar levels, to ask
a family member or friend for advice. |
1 |
2 |
3 |
4 |
5 |
24. |
When the person you care for has symptoms and
discovers that blood sugar is low, to eat or drink something with sugar
to solve the problem. |
1 |
2 |
3 |
4 |
5 |
25. |
If the person you care for finds out that blood
sugar is high, to adjust the diet to fix it. |
1 |
2 |
3 |
4 |
5 |
26. |
If the person you care for finds out that blood
sugar is high, to adjust physical activity to fix it? |
1 |
2 |
3 |
4 |
5 |
27. |
After taking actions to adjust an abnormal blood
sugar level, to re-check blood sugar to assess if the actions were effective. |
1 |
2 |
3 |
4 |
5 |
28. |
If the person you care for finds out that blood
sugar is very low or very high, to call your health care
provider for advice. |
1 |
2 |
3 |
4 |
5 |
Does the
person you care for take insulin?
Yes
No
If yes, please answer the
following question.
29. |
If the person you care for finds out that blood
sugar is too high or too low, to adjust the insulin dosage in the way your
health care provider suggested. |
1 |
2 |
3 |
4 |
5 |
SECTION D
People with diabetes have to
develop skills to take care of themselves and to maintain their health. In reference to the person you care for,
in general, how confident are you that you
can:
(circle one number)
|
|
NOT CONFIDENT AT ALL |
|
|
|
EXTREMELY CONFIDENT |
30. |
Prevent high or low blood sugar levels and its
symptoms. |
1 |
2 |
3 |
4 |
5 |
31. |
Follow advice about nutrition and physical activity. |
1 |
2 |
3 |
4 |
5 |
32.. |
Take medicines in the appropriate way (including insulin
if prescribed). |
1 |
2 |
3 |
4 |
5 |
33. |
Persist in following the treatment plan even when
it’s difficult. |
1 |
2 |
3 |
4 |
5 |
34. |
Monitor his/her blood sugar as often as the health
care provider asked that it be done. |
1 |
2 |
3 |
4 |
5 |
35. |
Understand if his/her blood sugar levels are good or
not. |
1 |
2 |
3 |
4 |
5 |
36. |
Recognize the symptoms of low blood sugar. |
1 |
2 |
3 |
4 |
5 |
37. |
Persist in monitoring his/her diabetes even when
it’s difficult. |
1 |
2 |
3 |
4 |
5 |
38. |
Take action to adjust his/her blood sugar and
relieve his/her symptoms. |
1 |
2 |
3 |
4 |
5 |
39. |
Evaluate if your actions were effective to change his/her
blood sugar and relieve his/her symptoms. |
1 |
2 |
3 |
4 |
5 |
40. |
Persist in carrying out actions to improve his/her
blood sugar even when it’s difficult. |
1 |
2 |
3 |
4 |
5 |
Thank you for completing this survey!