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
Full Name
Your answer
Address & Email id Phone number
Your answer
Q1.Age
Your answer
Q2.Birth Date
MM
/
DD
/
YYYY
Q3.sex
Q4.How many years have you been living with diabetes?
Q5. Any other medical problem apart from diabetes?
Your answer
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?
Q9.Which of the following best describes your current employment status? (check one box)
Q9.Do you test your blood sugar? (check one box)
Q9a.How many days a week do you test your blood sugar ? (days/week)
Your answer
Q9b.On days that you test, how many times do you test?(times/day)
Your answer
Q9c.Do you keep a record of your blood sugar test  results? (check one box)
Are you on insulin pump?
Q11. Are you on injections?
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