Question 1/21
Do you have Diabetes?
Yes
No
Question 2/21
What type?
Type I
Type II
Question 3/21
How do you treat your diabetes? (check all that apply)
Select
Check All
Diet/Lifestyle
Oral Medication
Insulin Injections
Insulin Pump
Question 4/21
How often do you check your blood sugar?
Select
Check All
Rarely
Less than once a day
If I feel I need to
More than once a day
Once a day
Question 5/21
What type of meter are you currently using?
Select
Check All
Aclu-Check
Contour
EasyMax
Element
Embrace
Fifty50
Flora
Fortis
Freestyle
Generic
Glucocard
Lifescan
Nova
Prodigy
ReliOn
Solus
WaveSense
Question 6/21
At what stage in your life did you learn of your diabetes?
Select
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From birth
As a Child
v
Twenties
Thirties
Forties
Fifties
Sixties
Seventies Plus
Question 7/21
Do you suffer from any of the following ailments that can be associated with Diabetes?
Select
Check All
Heart Disease
Diabetes Insipidus
Poor Circulation
Stroke
Weakened Immunity
Overweight
Inflammation
Kidney Disease
Obesity
Loss of limb
Nerve Pain
None
Question 8/21
Are you currently on Dialysis?
Yes
No
Question 9/21
Which of the following Medications do you use?
Select
Check All
Afreeza
Apidra
Exubera
Humalog
Humalog Kwikpen
Humalog Kwikpen 50/50
Humalog Kwikpen 75/25
Humalog Mix 50/50
Humalog Mix 75/25
Humulin 50/50
Humulin N
Humuline 70/30
Iletin
Lantus
Levemir
NovaLog Mix 70/30
Novolin R
Novolog
NovoLog FlexPen
Novolog Mix PenFill
Novolog Mix FlexPen
Relion Novolin
Sandostatin LAR
Symlin Pen
Velsulin
Question 10/21
Which of the following Medications do you use?
Select
Check All
ActoPlus Met
Actos
Amaryl
Apidra
Avandamet
Avandaryl
Avandia
Byetta
Cycloset
DiaBeta
Duetact
Exubera
Glucophage
Glucophage XR
Glucovance
Glycron
Glynase
Glynase PresTab
Glyset
Gucotrol
Humalog
Humalog Kwikpen
Humalog Kwikpen 50/50
Humalog Kwikpen 75/25
Humalog Mix 50/50
Humalog Mix 75/25
Humilin 70/30
Humulin N
Janumet
Januvia
Lantus
Lantus Solstar
Levemir
Novolin
Novolin N
Novolog Mix
Orinase
Prandimet
Prandin
Precose
Novolin 70/30
Relion
Rezulin
Riomet
Starlix
Symlin
Symlin Pen
Tolinase
Velosulin BR
Welchol
Question 11/21
Are you satisfied with your current treatment?
Yes
No
Question 12/21
Please explain why are you dissatisfied with your current treatment
Question 13/21
Are you interested in changing your treatment?
Yes
No
Question 14/21
What treatment(s) are you interested in switching to?
Question 15/21
Select the topics that most interest you in regards to your diabetes:
Select
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Diabetes treatments
Diabetes recipes
Health insurance
Blood glucose monitoring
Diabetes drugs
Alternative medicine
Question 16/21
Do you use Diabetic Socks or Hose?
Yes
No
Question 17/21
What month were you born?
Select Options
January
February
March
April
May
June
July
August
September
October
November
December
Question 18/21
Do you currently have medical insurance?
Yes
No
Question 19/21
Please select your current medical provider
Select Options
Aetna
BCBS
Cigna
Humana
United Health
Medicare/Medicade
Chubb
Global Life
Met Life
Mutual Life of Omaha
NY Life
State Farm
Question 20/21
What is the name of your provider?
Question 21/21
lease select the current medical coverage you have
Select Options
HMO
PPO
Medicare
Medicaid
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