Insulin Self-Administration Assessment Form
Evaluate your readiness and technique for safely and correctly administering insulin. All questions are required.
How confident are you in your ability to self-administer insulin?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you understand when you should administer your insulin?
*
Yes
No
Not sure
Which steps are you able to perform independently when preparing your insulin injection?
*
Rows
Always
Sometimes
Never
Gather supplies
1
2
3
Check insulin type and expiration
4
5
6
Draw up correct dose
7
8
9
Select and clean injection site
10
11
12
Dispose of sharps safely
13
14
15
How often do you rotate your injection sites?
*
Every time
Most times
Rarely
Never
How confident are you in recognizing signs of low or high blood sugar?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
If you miss a dose of insulin, do you know what steps to take?
*
Yes
No
Not sure
How do you store your insulin at home?
*
In the refrigerator
At room temperature
Not sure
How comfortable are you with disposing of used needles or syringes safely?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
If you experience symptoms of low blood sugar, what is your first response?
*
Eat or drink something sugary
Wait and see if symptoms improve
Call for medical help immediately
Not sure
Please rate your overall readiness to self-administer insulin safely and correctly.
*
1
2
3
4
5
Submit Assessment
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