You are free to submit the answers you have entered or can exit without ... Please answer it on behalf of your family member if you have their consent to do so.
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Thank you for agreeing to participate in this survey. Please read the questions carefully and answer as many as you think are relevant. You are free to submit the answers you have entered or can exit without submitting any time in between. Let us run through some of the common issues related to Diabetes care.
1. 1. Are you or someone in your family Diabetic? Yes No Don't know
2. How long have you or has your family member been suffering from Diabetes? Please give a range of time period since recognition of the disease. Please answer it on behalf of your family member if you have their consent to do so. 20 years
3. Do you know what is Diabetes? Please answer "Yes" if you have think you have basic understanding of what is the reason for Diabetes and how can it be treated, else answer "NO", if you think you need more information about Diabetes ,tick "Need more Info" Yes No Need more Info
4. What medications do you use to treat your Diabetes and other associated illness? Please check all the types of medications that is on your current prescription. Anti-Diabetic medications
5. Are you satisfied with the control of your Diabetes and other associated illness? Please move the slider to indicate your current mood about your Diabetes.
Not under control
Almost under control
Well under control
6. How often do you meet your doctor for Diabetes check up? Once in a month Twice a month Twice in six months Twice in a year Once a year Not seen a doctor for >2 years Not seen a doctor > 4 years
7. What was the reason for seeing doctor only twice or less in a year? Please tick the reasons for you to have not seen your Diabetes doctor more than twice in the last year. The answers given here are only for assessing the level of awareness about Diabetes. My Diabetes is under control
My medications refill is once in six months Doctors not available more frequently Medications are available without doctor's consultations Medications are costly I take medications only if very sick My realtives/friends refill is used for my medications I do not like to take medications regularly
8. What is your opinion about your health care provider? This rating is your own subjective assessment and is to know about ways for improvement of present healthcare. Rate on increasing order of satisfaction with one 1 being least satisfied and 5 as very satisfied. 1 2 3 4 5
9. Do you take your medications regularly to control Diabetes? Yes No I try to take regularly but miss medications once in a month I miss medications more than twice a month I think it is OK to miss medications Taking regular mediacations is impossible for me
10. What is the reason for you to not take regular medications for Diabetes and other associated illness? If you have answered that you do not take regular medications in the previous question, then please answer the choices below. No access to hospital or Pharmacy Medications costs are not affordable for regular use Insulin syringes not available
My prescribed Insulin is not available in local Pharmacy I have allergic reactions to medications I need assistance to go to pharmacy
11. Please specify your Gender. Male Female Do not want to disclose
12. How old are you? 18 to 25 years 26 to 35 years 36 to 45 years 46 to 55 years 55 to 65 years >65 years
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13. Do you have insurance coverage for Diabetes? Please indicate YES if you have some kind of insurance assistance , answer NO if you have no Insurance coverage, answer OTHER if you have any other kind of medical assistance or free medical services available. Yes No Other
14. What is the most important need that you want the health care services to provide for Diabetes care? Availabilty of doctors for prompt care Avalability of health care provider within 5 miles of your resisdence Cheaper anti-Diabetic medications and Syringes Information about Diabetes control Nutrition related information Exercise related information Acess to healthcare as and when needed Psychological support Life style support programs Health education about Diabetes control
15. Do you know how and what foods in your daily diet influence Diabetes control? Yes No Would love to have more info
16. How has your mood and psychological state been on an average day? Please answer this to tell if stress of having to keep Diabetes under control affected your daily life?
Sad
Neutral
Happy
17. How would you rate your present Diabetes care providers services? Please rate the care providers services on the sliding scale between 1 to 5 with I being terrible or bad and the 5 being best possible. Rate your opinion about the Diabetes care you now get in your place.
18. *How much do you think your routine choices about food,sleep,smoking,alcohol and exercise affect Diabetes control? Rank your choices from 1 to 9 depending on what place would you give each category. Answer only questions that are relevant to you. Answer as many as found appropriate. Please ignore questions about smoking, alcohol and sleep aids if you do not use it more than twice a week. Nutritional quality decides my Diabetes control Cost of available food affects my menu and Diabetes control Junk food affects my Diabetes control Smoking affects my Diabetes and medication use Alcohol cost affects my menu and Diabetes medication use Use of Sleep aids medications affect my diabetes Medications Doctor consultations affects my Diabetes control Insurance affects my Diabetes control Use of Gym or Exercise programs affects my Diabetes control
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Thank you for investing time thinking about Diabetes and control. Your answers will help us understand and improve Diabetes control programs. Thank you for taking the survey.
