Section I - Demographics
Please answer each of the following questions by filling in the blanks with the correct answers or by choosing the best answer
Address & Email id Phone number
Prefer not to say
Q4.How many years have you been living with diabetes?
less than year
1 to 5 years
6 to 10 years
11 to 15 years
More than 15 years
Q5. Any other medical problem apart from diabetes?
Q6. What is your marital status? (check one box)
Q7. If married , how many kids you have
Q8. What is your highest formal education completed?
High school graduate (Till 12th)
Q9.Which of the following best describes your current employment status? (check one box)
Unemployed or laid off and looking for work
Unemployed and not looking for work
Disabled, not able to work
Something else? (Please specify):
Q9.Do you test your blood sugar? (check one box)
Q9a.How many days a week do you test your blood sugar ? (days/week)
Q9b.On days that you test, how many times do you test?(times/day)
Q9c.Do you keep a record of your blood sugar test results? (check one box)
Only Unusual Values
Are you on insulin pump?
Q11. Are you on injections?
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