I am a
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Male
Female
Gender - Hidden
M
F
My date of birth
*
-
Year
-
Month
Day
Date
My age is
*
I identify as
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Aborigine
Torres St. Islander
Thursday Islander
European
South East Asan
South Pacific Islander
New Zealander
Indian
Chinese
Japanese
None of the above
The type of diabetes I live with is
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Type 1
Type 2
I have had Type 1 diabetes for
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Newly diagnosed
Less than 5 years
Between 5 and 10 years
Between 11 and 20 years
More than 20 years
I have had Type 2 diabetes for
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Newly diagnosed
Less than 5 years
Between 5 and 10 years
Between 11 and 20 years
More than 20 years
I have had diabetes for - Hidden
0
1
2
3
4
I am seeing a specialist for my Type 1 diabetes management
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Yes
No
I am seeing a specialist for my Type 2 diabetes management
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Yes
No
I last saw the specialist
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-
Year
-
Month
Day
Date
I last saw the specialist
*
-
Year
-
Month
Day
Date
I manage my Type 1 diabetes with ( select which applies )
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Insulin Pump
Basal and meal insulin injections
I manage my Type 2 diabetes with ( select all that apply )
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Diet alone
Tablets
Injections
Non prescription therapy
Oral glucose lowering therapy
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Actos
Amaryl
Diamicron
Diabex
Forxiga
Galvus
Galvumet
Gliclazide
Glimepiride
Glucobay
Januvia
Janumet
Jardiance
Jardiamet
Kombiglyze
Metformin
Minidiab
Nesina
Nesinamet
Onglyza
Trajenta
Trajentamet
Xigduo
Injections
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Actrapid
Apidra
Bydureon
Byetta
Humalog
Humalog Mix
Lantus
Levemir
Mixtard
Novomix
Novorapid
Ryzodeg
Trulicity
Victoza
I also take medications from the following families in order to
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Control BP
Lower cholesterol
Control blood glucose
Prevent angina
Thin blood
Improve mood (antidepressants)
Reduce pain in feet
I am not sure what my medications do
None of the above
Medications
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Less than 5
5 or more
Immunisations
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Current
Not Current
My influenza vaccination is
My pneumococcal vaccination is
I do not get immunised
Which of the following do you have most difficulty with or concern for when it comes to living with your diabetes?
Food choices
Food portion or quantity control
Exercise
Testing my blood glucose
Fear that I will need insulin
Understanding diabetes ins and outs
Medications
Complications
None of the above
Submit
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