Personal Diabetes Health Questionnaire
Please complete this questionnaire to help assess your diabetes health, lifestyle, and self-management practices. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What type of diabetes have you been diagnosed with?
*
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Other / Not sure
How many years have you had diabetes?
*
Please indicate your most recent HbA1c result (if known)
Please Select
Below 6.5%
6.5% - 7.0%
7.1% - 8.0%
8.1% - 9.0%
Above 9.0%
Not sure/Don't know
In the past 2 weeks, have you experienced any of the following symptoms? (Select all that apply)
Frequent thirst
Frequent urination
Unexplained weight loss
Blurred vision
Fatigue
None of the above
Other
Please indicate how often you perform the following diabetes self-management tasks:
*
Rows
Never
Rarely
Sometimes
Often
Always
Monitor blood glucose
1
2
3
4
5
Take medication as prescribed
6
7
8
9
10
Attend medical appointments
11
12
13
14
15
Follow recommended diet
16
17
18
19
20
Exercise regularly
21
22
23
24
25
Please rate your overall satisfaction with your diabetes management.
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
Do you smoke or use tobacco products?
No
Yes, occasionally
Yes, daily
Former user
Do you drink alcohol?
No
Yes, occasionally
Yes, regularly
Please list your current diabetes medications (if any)
Do you have any family history of diabetes?
Yes
No
Not sure
Submit Questionnaire
Should be Empty: