Diabetes Care Treatment Selection Survey Form
Please share your preferences and factors important to you in selecting diabetes care and treatment options. Your responses will help us understand your needs and support your care journey.
Which type of diabetes care approach do you most prefer?
*
Medication-based treatment
Lifestyle modification (diet/exercise)
Combination of medication and lifestyle changes
Other
How important are the following factors in your diabetes treatment selection?
*
Rows
Not important
Somewhat important
Very important
Cost of treatment
1
2
3
Convenience of treatment
4
5
6
Potential side effects
7
8
9
Frequency of doctor visits
10
11
12
Flexibility in daily routine
13
14
15
How comfortable are you with using injectable medications (such as insulin)?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
How likely are you to follow a recommended diet and exercise plan as part of your diabetes care?
*
Not likely
1
2
3
4
Very likely
5
1 is Not likely, 5 is Very likely
Which of the following do you consider the biggest challenge in managing your diabetes?
*
Remembering to take medication
Maintaining a healthy diet
Finding time for exercise
Managing stress
Other
How would you rate your satisfaction with your current diabetes care plan?
*
1
2
3
4
5
How confident do you feel about managing your diabetes on your own?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you have access to a support system (family, friends, groups) to help with your diabetes care?
*
Yes
No
Not sure
What would you most like to improve about your diabetes care experience?
Submit
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