The Michigan Diabetes Research and Training Center (MDRTC) has developed several survey instruments for diabetes patients and health professionals. By downloading the forms you are agreeing to acknowledge the MDRTC as the source of the items in the survey instruments in any written instruments, reports, or publications resulting from their use or reproduction.
Please select the instruments you would like to download from the list below . These instruments are all available in both Word format and PDF format. (Adobe Acrobat Reader is required to view and print PDF files. If you don't already have Adobe Acrobat Reader, you can download it for free now.)
- Diabetes Care Profile (DCP)
- Diabetes History (DMH)
- Diabetes Knowledge Test (DKT)
- Diabetes Attitude Scale (DAS-3)
- Diabetes Empowerment Scale (DES)
- Michigan Neuropathy Screening Instrument (MNSI)
- Risk Perception Survey for Developing Diabetes (RPS-DD)
The DCP is a self-administered questionnaire that assesses the social and psychological factors related to diabetes and its treatment. The instrument contains 234 items and sixteen scales. These scales assess the patients' diabetes attitudes, diabetes beliefs, self-reported diabetes self-care, and difficulties with diabetes self-care. The DCP also contains questions concerning demographic information and self-care practices. Respondents can complete the questionnaire in approximately 30 to 40 minutes.
- Diabetes Care Profile (DCP) [Word or PDF ]
- Diabetes Care Profile Scale Formulae [Word or PDF]
- List of articles concerning or using the DCP [Word or PDF]
The Diabetes History form is used by the Michigan Diabetes Research and Training Center (MDRTC) to collect basic clinical diabetes information from community-based patients involved in a variety of MDRTC projects. The Diabetes History was revised in 1998, with the addition of sections on resource use, patient satisfaction, and potential comorbidities. The revised Diabetes History (version 2.0) consists of five sections of core questions and four sections of additional questions as appendices, which can be added to the core instrument depending upon the needs of the user. The survey instrument is designed to be self-administered.
Core questions include items on the following topics:
- Section 1 - Resource Use
- Section 2 - Medication Use and Medication Changes
- Section 3 - Satisfaction with Diabetes
- Section 4 - Potential Comorbidities
- Section 5 - Demographic / Background Information
Questions included in the DMH appendices, which can be added to the core instrument (as a new section), include items on the following topics:
- Section 6 - Reasons for coming to the clinic
- Section 7 - Diabetes and pregnancy
- Section 8 - Reasons for changing the timing and/or dose of medication
- Section 9 - Diet / nutrition counseling
There are also a few additional questions included in the DMH appendices, which can be added to an existing section of the core instrument.
The Diabetes Knowledge Test consists of 23 knowledge test items developed by the Michigan Diabetes Research Training Center (MDRTC). These 23 items represent a test of general knowledge of diabetes. The first 14 items are appropriate for people who do not use insulin. The entire 23 items can be administered to people who do use insulin. The psychometric properties provide information regarding the reliability of the various groups of items, as well as a difficulty index (percent of patients who scored this item correctly), and an item to group total correlation for each item. These data can be reported when describing the use of the test. This test is not recommended for the evaluation of self-management education programs because the items have not been matched to the particular educational content of the program. Educators wishing to do program evaluation may use some of the items on this test, but they should be certain that there is a good item-to-program content match. The 23-item test takes approximately 15 minutes to complete.
Select the document pertaining to the DKT you would like to download by clicking on the link:
- DKT with answers [Word or PDF]
- DKT without answers [Word or PDF]
- DKT Modified True/False Version [PDF]
- DKT Modified True/False Version Description [PDF]
- List of articles concerning or using the DKT [Word or PDF]
- Table of Test Reliabilities for the DKT [Word or PDF]
The Diabetes Attitude Scale can be used with both people with diabetes and health care professionals as a measure of general diabetes related attitudes. Information about the scoring and psychometric properties of this scale is also available here.
Select the document pertaining to the DKT you would like to download by clicking on the link:
- Diabetes Attitude Scale (DAS-3) [Word or PDF]
- Diabetes Attitude Scale - 3 Formulae [Word or PDF]
- List of articles using the DAS [Word or PDF]
In 2000 we developed the Diabetes Empowerment Scale (DES) to measure the psychosocial self-efficacy of people with diabetes. The original questionnaire contained 37 items representing 8 conceptual dimensions (i.e. assessing the need for change; developing a plan; overcoming barriers; asking for support; supporting oneself; coping with emotion; motivating oneself; and making diabetes care choices appropriate for one's priorities and circumstances). Using factor analyses the questionnaire was reduced to the current 28-item DES alpha= 0.96 containing three subscales. (1) The three subscales are: 1) managing the psychosocial aspects of diabetes with 9 items, alpha= 0.93; 2) assessing dissatisfaction and readiness to change with 9 items alpha = 0.81; and 3) setting and achieving goals with 10 items, alpha = 0.91. In addition to providing an overall assessment of diabetes related psychosocial self-efficacy the three subscales of the DES allow for an examination of its underlying components.
In order to allow for a brief overall assessment of diabetes related psychosocial self-efficacy, we developed an eight item short form of the DES (the DES-SF). The DES-SF was created by choosing the item from the (remaining 28 items appeared in the published article but it is an error. It should say the original 37 items. This is a typographical error (ours) but it does not affect any of the psychometric data found in this article) items with highest item to subscale correlation from each of the original eight conceptual domains. The reliability of the DES-SF using the original data set was alpha = 0.85. We have subsequently administered the DES-SF to 229 subjects in a new study. The reliability of the DES-SF using the data from the new sample was alpha = 0.84. The content validity of the DES-SF was supported in the new study by the fact that both DES-SF scores and HbA1c levels changed in a positive direction after the 229 subjects completed a six-week problem based patient education program (2). The change in DES-SF scores and HbA1c levels were not correlated suggesting that these two measures vary independently.
These data provide preliminary evidence that the DES-SF is a valid and reliable measure of overall diabetes-related psychosocial self-efficacy.
1) Anderson RM, Funnell MM, Fitzgerald JT, Marrero DG: The diabetes empowerment scale: a measure of psychosocial self-efficacy. Diabetes Care 23:739-743, 2000
2) Anderson RM, Funnell MM, Nwankwo R, Gillard ML, Fitzgerald JT, Oh M: Evaluation of a problem-based, culturally specific, patient education program for African Americans with diabetes. Diabetes 50(Suppl. 2): A195, 2001
3) Anderson RM, Fitzgerald JT, Gruppen LD, Funnell MM, Oh MS: The diabetes empowerment scale-short form (DES-SF). Diabetes Care 26:1641-1643, 2003
Select the document pertaining to the DES you would like to download by clicking on the link:
- DES - Long Form in English [Word or PDF]
- DES - Long Form in Spanish [Word or PDF]
- DES - Short Form in English [Word or PDF]
- DES - Short Form in Spanish [Word or PDF]
- Diabetes Empowerment Scale (DES) Scoring Key [Word or PDF]
- List of articles concerning or using the DES [Word or PDF]
The Michigan Neuropathy Screening Instrument (MNSI) is designed to screen for the presence of diabetic neuropathy. The MNSI is designed to be used in an outpatient setting by primary care or other providers. The first part of the screening instrument consists of 15 self-administered "yes or no" questions on foot sensation including pain, numbness and temperature sensitivity. A higher score (out of a maximum of 13 points) indicates more neuropathic symptoms.
The questions were chosen from among those in the Neuropathy Screening Profile of Peter Dyck that showed the highest degree of specificity and sensitivity for diabetic neuropathy among normal subjects and those with a variety of neuromuscular disorders (Neurology, 36:1300-1308, 1986).
The second part of the MNSI is a brief physical examination involving 1) inspection of the feet for deformities, dry skin, hair or nail abnormalities, callous or infection, 2) semi-quantitative assessment of vibration sensation at the dorsum of the great toe, 3) grading of ankle reflexes and 4) monofilament testing. Patients screening positive on the clinical portion of the MNSI (greater than 2 points on a 10 point scale) are considered neuropathic and referred for further evaluation.
Select the document pertaining to the MNSI you would like to download by clicking on the link:
- MNSI Patient version [Word or PDF]
- MNSI Scoring version [Word or PDF]
- How to use the MNSI [Word or PDF]
- List of articles concerning or using the MNSI [Word or PDF]
A self-administered OR telephone interview questionnaire that assesses risk perception and modifiers of risk perception among women with histories of GDM who have not developed postpartum diabetes. The instrument contains 4 scales assessing modifiers of risk perception. These scales assess the patients' knowledge of diabetes risk factors, perceptions of personal control, optimism about developing diabetes and other diseases, and perceptions of the benefits and barriers of preventive behaviors. Respondents can answer these questions in approximately 5 minutes. The instrument also contains 2 scales assessing actual risk perception.
Select the document pertaining to the RPS-DD you would like to download by clicking on the link: