Insulin Delivery Method Assessment Form
Please complete this assessment to help us better understand your current insulin delivery experience and preferences.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which of the following best describes your current insulin delivery method?
*
Insulin Pen
Insulin Pump
Syringe/Vial
Other
How long have you been using your current insulin delivery method?
*
Please Select
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
Please rate your satisfaction with your current insulin delivery method.
*
1
2
3
4
5
Please indicate how often you experience the following challenges with your current insulin delivery method.
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty with injections/infusions
1
2
3
4
5
Pain or discomfort
6
7
8
9
10
Device malfunction or errors
11
12
13
14
15
Forgetting doses/times
16
17
18
19
20
Difficulty carrying equipment
21
22
23
24
25
How many times per day do you typically administer insulin?
*
Are you interested in learning about alternative insulin delivery methods?
*
Yes
No
Maybe
Have you experienced any adverse events (such as hypoglycemia, skin irritation, or infection) related to your insulin delivery method?
*
Hypoglycemia
Skin irritation
Infection
None
Other
Please share any additional comments or suggestions regarding your insulin delivery experience.
Submit Assessment
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