| The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 12 weeks, please specify the extent to which each statement applies to you. | Strongly Agree | Agree | Neither | Don’t Agree | |
| 1 | I check my blood sugar levels with care and attention. ☐ Blood sugar measurement is not required as a part of my treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 2 | The food I choose to eat makes it easy to achieve optimal blood sugar levels. | ☐3 | ☐2 | ☐1 | ☐0 |
| 3 | I keep all doctors’ appointments recommended for my diabetes treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 4 | I take my diabetes medication (e. g. insulin, tablets) as prescribed. ☐ Diabetes medication/insulin is not required as a part of my treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 5 | Occasionally I eat foods with a lot of simple sugars eg. Refined sifted flour, table sugar, jams, honey, soft drinks | ☐3 | ☐2 | ☐1 | ☐0 |
| 6 | Occasionally I eat foods with complex sugars eg. Green vegetables, pasta, whole grain, bread, beans, corn, sweet potato | ☐3 | ☐2 | ☐1 | ☐0 |
| 7 | I record my blood sugar levels regularly (or analyse the value chart with my blood glucose meter). ☐ Blood sugar measurement is not required as a part of my treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 8 | I tend to avoid diabetes-related doctors’ appointments. | ☐3 | ☐2 | ☐1 | ☐0 |
| 9 | I do regular physical activity to purposelyachieve optimal blood sugar levels. | ☐3 | ☐2 | ☐1 | ☐0 |
| 10 | I strictly purposely follow the dietary recommendations given by my doctor or diabetes specialist. | ☐3 | ☐2 | ☐1 | ☐0 |
| 11 | I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control. ☐ Blood sugar measurement is not required as a part of my treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 12 | I avoid physical activity, although it would improve my diabetes. | ☐3 | ☐2 | ☐1 | ☐0 |
| 13 | I tend to forget to take or skip my diabetes medication (e.g. insulin, tablets). ☐ Diabetes medication/insulin is not required as a part of my treatment. | ☐3 | ☐2 | ☐1 | ☐0 |
| 14 | Sometimes I have real “food binges” (not triggered by hypoglycaemia). | ☐3 | ☐2 | ☐1 | ☐0 |
| 15 | Regarding my diabetes care, I should see my medical practitioner(s) more often. | ☐3 | ☐2 | ☐1 | ☐0 |
| 16 | I tend to skip planned physical activity. | ☐3 | ☐2 | ☐1 | ☐0 |
| 17 | My diabetes self-care is poor. | ☐3 | ☐2 | ☐1 | ☐0 |