Specific Carbohydrate Diet Program Assessment
A preliminary assessment of Crohn's patients (& families) to determine the needs in a Specific Carbohydrate Diet health education program.
Email address *
Age (years) *
Your answer
Gender *
Race *
Required
Highest degree level/education obtained *
What is your occupation? *
How many hours a week do you spend on work/school? *
Your answer
What time of the day do you spend at work/school? (Choose all that are applicable). *
Required
My work is associated with: (check all that apply) *
Required
Select the best description of you. *
City of Residence *
Your answer
State of Residence *
Your answer
How many people (INCLUDING you) live in your household? *
Your answer
How would you categorize your primary role model? *
How long ago were you (or the patient you know) diagnosed with Crohn's disease? *
Is the condition currently in remission (no symptoms/stable)? *
Would you rather control your Crohn's disease with medications or a guided nutrition program limiting certain foods? *
Have you tried the Specific Carbohydrate Diet? *
How knowledgeable are you about the Specific Carbohydrate Diet? *
Select the following SCD resources you have heard of and found helpful. *
Required
Select the following SCD resources you have heard of and did NOT find helpful. *
Required
What is your level of interest in participating in a program to adopt the Specific Carbohydrate Diet? *
Who would you prefer as the primary person who delivers the information? *
Who would you like to interact with during the program? (Select all that apply) *
Required
Please respond to the following questions with the most appropriate response. *
Very good
Good
Neither good nor poor
Poor
Very poor
How would you rank your physical health?
How would you rank your mental health?
How would you rank your work/academic progress?
How would you rank your work/school attendance?
How would you rank your pride in how you eat?
How well are you able to set boundaries with your family.
How would you rank your ability to set boundaries with your peers?
What is your current attitude towards the Specific Carbohydrate Diet?
Please select the response that is most accurate to you for each statement. *
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I feel I have enough support from my family to adopt the Specific Carbohydrate Diet.
I feel I have enough support from my friends to adopt the Specific Carbohydrate Diet.
I feel I have enough support from my doctor to adopt the Specific Carbohydrate Diet.
I feel I have enough support from my school/work to adopt the Specific Carbohydrate Diet.
I feel I have enough support from my grocery store to adopt the Specific Carbohydrate Diet.
I feel I have enough support in my home environment to adopt the Specific Carbohydrate Diet.
I believe the Specific Carbohydrate Diet alone (no medications) can manage my Crohn’s disease.
I believe I can change how I eat and eliminate certain ingredients from my diet.
I have to eat the same way others are eating in a social situation in order for it to be enjoyable.
I believe the Specific Carbohydrate Diet can be affordable for just the patient.
I believe the Specific Carbohydrate Diet can be affordable for a family.
I would prefer everyone in my household to eat the SCD, or at least very similar.
I have the discipline I need to make a lifestyle change in the way I eat.
I would like to share new recipes and products with others.
I think it is important for me to eat healthy.
I care enough about my health to eat healthy.
I think there are enough resources available for me to adopt the Specific Carbohydrate Diet.
I am nervous about adopting the Specific Carbohydrate Diet.
I am excited about adopting the Specific Carbohydrate Diet.
I feel like I have control over what I eat.
I enjoy learning.
I am responsible for my own health.
I enjoy baking and cooking.
I enjoy planning meals for the week.
I enjoy grocery shopping.
I am comfortable reading ingredient labels.
I enjoy teaching others.
My needs in life are being satisfied.
I am denied opportunities to pursue happiness and fulfillment.
I can find SCD-safe products online or in store.
I can identify a SCD-safe product.
I can cook a SCD-safe meal.
I can modify a non-SCD recipe to a SCD-safe one.
I can modify a non-SCD meal at a restaurant to make it a SCD-safe one.
I am comfortable discussing my diagnosis and/or the Specific Carbohydrate Diet with others.
What is your PER PERSON monthly budget for groceries? *
Your answer
Do you have access to internet at home? *
How motivated are you to start the SCD or learn more about it if already on it? *
Rank your preference of a learning platform for the program. (7=most favorable, 1=least favorable) *
1
2
3
4
5
6
7
Pre-recorded videos
Pre-recorded podcasts/audio
A book
In person presentations
Virtual live presentations
Website/Blog
Workbook
Would you like the program to be at your own pace or on a schedule? *
How long would you commit to a learning program? *
Required
Select where you would consider participating in the program? *
Can I follow up with you for further clarification and/or to help with interpretation of participants ' answers? *
Rank the following barriers to adopting the Specific Carbohydrate Diet. *
Big barrier
Barrier
Somewhat of a barrier
Not a barrier
Knowledge of SCD
Time for grocery shopping
Time for meal preparation
Eating out
Cooking techniques
Friend influence
Family influence
Home environment
Work/school environment
Self-discipline
Cravings for non-SCD foods
Other
Rank the following rewards that encourage you to repeat a behavior (6=greatest, 1=least) *
5
4
3
2
1
Physical benefits
Recognition/compliments from your elders
Recognition/compliments from your peers
Prize/gift
Advice/feedback