Transition Readiness Questionnaire

	A	B	F	G	H	I	J	K
1	Transition Readiness Questionnaire
2	Instructions: We would like to know how you describe your skills in several areas that may be important for managing your diabetes care in the future. There are no right or wrong answers, and your answers will remain confidential and private.
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4			I do not need to do this	I do not know how but I want to learn to do this	I am learning to do this	I am starting to do this	I always do this when I need to
5	1	Do you manage your diabetes on your own (without your parents' help)?	1	2	3	4	5
6	2	Do you reorder your diabetes supplies before they run out?	1	2	3	4	5
7	3	Do you fill your prescriptions?	1	2	3	4	5
8	4	Do you arrange for your ride to medical appointments?	1	2	3	4	5
9	5	Do you call the doctor's office to make an appointment?	1	2	3	4	5
10	6	Do you take care of your medical equipment and supplies?	1	2	3	4	5
11	7	Do you kow the side effects or bad reactions of each medication you take?	1	2	3	4	5
12	8	Do you know what to do if you are having a bad reaction to your medication?	1	2	3	4	5
13	9	Do you call the doctor about unusual changes in your health?	1	2	3	4	5
14	10	Do you follow up on any referral for tests or check-ups or labs?	1	2	3	4	5
15	11	Do you manage your money and budget your expenses on your own?	1	2	3	4	5
16	12	Do you pay or arrange payments for your medications?	1	2	3	4	5
17	13	Do you know what your insurance covers?	1	2	3	4	5
18	14	Do you apply for health insurance if you lose your current coverage?	1	2	3	4	5
19	15	Do you arrange payment for your medical equipment and supplies?	1	2	3	4	5
20	16	Do you answer questions that are asked by the doctor, nurse, or clinic staff?	1	2	3	4	5
21	17	Do you tell the doctor or nurse what you are feeling?	1	2	3	4	5
22	18	Do you keep your home/room clean?	1	2	3	4	5
23	19	Do you ask questions of the doctor, nurse, or clinic staff?	1	2	3	4	5
24	20	Do you help plan meals/food?	1	2	3	4	5
25	21	Do you help prepare meals/food?	1	2	3	4	5
26	22	Do you fill out the medical history form, including a list of your allergies?	1	2	3	4	5
27	23	Do you keep a calendar or a list of medical and other appointments?	1	2	3	4	5
28	24	Do you request the accomodations and support you need at school or work?	1	2	3	4	5
29	25	Do you apply for a job or work or vocational services?	1	2	3	4	5
30	26	Do you call on and use community support services (ex. after-school programs) when you need them?	1	2	3	4	5
31	27	Do you make a list of questions before the doctor's visit?	1	2	3	4	5
32	28	Do you remember when your blood sugar should be tested?	1	2	3	4	5
33	29	Do you make sure you carry sugar in case of a low blood sugar reaction?	1	2	3	4	5
34	30	Do you make sure you always have your supplies (such as insulin, syringes, testing, CGM, or pump supplies)?	1	2	3	4	5
35	31	Do you check expiration dates on insulin and supplies?	1	2	3	4	5
36	32	Do you notice differences in your health, such as weight changes or signs of infection?	1	2	3	4	5
37	33	Do you remember to make appointments with doctors and dentists?	1	2	3	4	5
38	34	Do you program the pump basal and/or temporary basal rates?	1	2	3	4	5	I don't have an insulin pump (999)
39	35	Do you review your CGM trends/data?	1	2	3	4	5	I don't have a CGM (999)
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