Diabetes Self Management Evaluation questionnaire

Diabetes is a disease which will stay with you for life, therefore it is important that you devise a way to deal with all aspects of your disease, in order to delay the complications or avoid them altogether!

The Diabetes Self Management Evaluation questionnaire below will help you in getting a sound idea of

a) How well aware you are of your disease

b) How well you are managing it

Take a print out of the form , answer the questions below and upload your filled up form, we will analyze it and get back to you within 24 hours

______________________________________________________________________________

Your age:

Your gender:

Your marital status:

Current occupation:

Family members with diabetes (tell us how they are related to you):

(For the following questions, choose whichever option is applicable for you; ‘Y’ means yes and ‘N’ means no  and  in questions with multiple options  , tick ALL that apply for you)

1. Which type of diabetes do you have?

Type 1/Type 2/GDM/Prediabetes/Don’t know

2. For how many years have you had diabetes?

Your answer: _____________________________

3. Which type of medicines do you take for your diabetes?

Oral medicines/insulin/injection other than insulin (e.g. Byetta)

4. When (how many months ago) was your last HbA1c done and what was the value?

Your answer: _____________________________________

5. Do you take any other medicines regularly? Y /  N

If yes, tell us the names and dosage

Your answer: ________________________________________________________________

6. Do you have a meal plan for diabetes?    Y /  N

About how often do you use this meal plan? Never/Seldom/Sometimes/Usually/Always

7. Do you read and use food labels as a dietary guide?  Y /  N

8. Do you have any diet restrictions: Salt /Fat /Fluid /None/ sugar/ any other

9. Give a sample of your meals for a typical day:

Breakfast:________________________________________________________Time:

Lunch: ___________________________________________________________Time:

Dinner: __________________________________________________________ Time:

Snack:_____________________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________Time:

Snack: _____________________­­­­­­­­­­­­­­­­­­­­­______________________________________Time:

10 . Do you:  Do your own food shopping?      Y /  N

   Cook your own meals?                  Y /   N

11 . How often do you eat out? (Including canteen food in office or ordering in/home delivery)

2-3 days in a week or more/less than once in week /less than once in month

12 . Do you drink alcohol?      Y /  N

Type: ______   How many_____ per day   per week

13. Do you use tobacco?: Cigarette / pipe/ cigar/ chewing/none/quit more than a year ago/quit recently

14. Do you exercise regularly?    Y  /   N

  • What type of exercise: ____________________
  • How Often:___________________
  • Your exercise routine is: easy/moderately intense/very intense

15. Do you check your blood sugars by glucometer?      Y / N

  • How often: Once a day/2 or more/day    1 or more/Week     Occasionally
  • When: Before breakfast/ Before bedtime/ Before meals/ After meals
  • What is your target blood sugar range?

Before meals/fasting:­­­­­­­­­­­­­­­­­___________________

After meals:  _________________

16. In the last month, how often have you had a low blood sugar reaction: Never/ Once / One or more times/week

What are your symptoms? ________________________

How do you treat your low blood sugar? __________

17. Can you tell when your glucometer reading is too high?         Y /  N

Above what level will you consider a sugar reading high e.g. 200/250/300

What do you do when your sugar is high?          ____________________________________________________

18. Have you had any of the following tests/procedures in the last 12 months:

  • Dilated eye exam: Y / N
  • Urine test for protein or micro albumin: Y / N
  • Foot exam—by healthcare professional :  Y / N
  • Dental exam : Y / N
  • Blood pressure: Y / N
  • Weight: Y / N
  • Cholesterol : Y / N
  • HbA1c : Y / N
  • Flu shot : Y / N

19. In the last 12 months, have you: used emergency room services / been admitted to a hospital?

  Y /N

If yes, was ER visit or hospital admission diabetes related?   Y/  N

20. Do you have any of the following: eye problems /kidney problems/ numbness or tingling or loss of feeling           in your feet/ dental problems /high blood pressure/high cholesterol /sexual problems /depression /none

21. Have you had previous instruction on how to take care of your diabetes? Y N

How long ago: ________

22. In your own words, what is diabetes?

23. What are the complications of diabetes?

24. Please state whether you agree, are neutral or disagree with the following statements:

  • I feel good about my general health: agree/     neutral/     disagree
  • My diabetes interferes with other aspects of my life: agree/   neutral/    disagree
  • My level of stress is high: agree/    neutral/    disagree
  • I have some control over whether I get diabetes complications or not: agree/     neutral/   disagree
  • I struggle with making changes in my life to care for my diabetes: agree/  neutral/    disagree

25. How do you handle stress?

26. What concerns you most about your diabetes?

27. What is hardest for you in caring for your diabetes?

28.What are your thoughts or feelings about this issue (e.g., frustrated, angry, guilty)?

 

 29. What are you most interested in learning from us about diabetes?

  1. Pregnancy and Fertility (for women)

Are you:  Pre-menopausal   /  Menopausal    / Post-Menopausal

Are you pregnant?  Y –When are you expecting? ________________________

N –Are you planning on becoming pregnant?_____________

Have you been pregnant before?  Y     N

Do you have any children?  Y –Ages: _____________ N

Are you aware of the impact of diabetes on pregnancy?  Y  /   N

Are you using birth control? Y / N , If yes, what method do you use?

CHECK OUT: Our references for diabetes mellitus

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