Diabetes Education Questionnaire

June 8, 2011

  1. Name:
  1. Gender
  1. Age:
  1. When was your diabetes first detected:
  1. When did you think it was time to get yourself tested for diabetes:
  1. What treatment were you given initially:

a)   insulin  b)tablets  c)change in diet  d)exercise  e)none  f)others(please specify)

  1. How do you test your own sugar level:

a) Blood test at the doctor’s clinic

b) Blood glucose test at home

c) Urine glucose test strips at home

d) Others

7.   How often do you test your sugar level?

a) Never   b) once a week   c) once a day   d) once a month

8.   Do you own a glucose meter? If yes, which company?

  1. Do you eat/drink special diabetic food items?

a) Yes     b) no

  1. Has your doctor ever informed you that your diabetes can cause amputation?

a) Yes    b) no    c) not aware

  1. What kind of a doctor keeps check of your diabetes?

a) General physician        b) diabetes specialist     c) No idea

12.   During the past one year, has your doctor examined your feet?

a) Yes           b) no

13.   Have you got the retina of your eyes checked?

a) Yes           b) no

Download Sample Diabetes Education Questionnaire in Word Format

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