Diabetes-related questions
1. How many times, during the preceding year, have you visited a doctor? (please circle the most appropriate alternative)
Due to diabetes0 1-2 3-4 5-6 7-8 More than 8 times
Due to other reasons0 1-2 3-4 5-6 7-8 More than 8 times
please specify ?______
2. How many times, during the preceding year, have you visited a nurse (please circle the most appropriate alternative)
Due to diabetes0 1-2 3-4 5-6 7-8 More than 8 times
Due to other reasons0 1-2 3-4 5-6 7-8 More than 8 times
please specify ?______
3. How much does diabetes per se and/or its treatment disturb your normal life? (please circle one)
1Not at all
2Slightly
3Moderately
4Quite a lot
5Very much
4. How much do the potential diabetes related complications disturb your normal life? (please circle one)
0I do not have any complications
1Not at all
2Slightly
3Moderately
4Quite a lot
5Very much
5. What is your last measured HbA1c value? ______%
6. What does this above-mentioned value tell about an average daily glycaemic control during the preceding 6-8 weeks? (please circle one)
1That it is at a good level
2That it is at a satisfactory level
3That it is at a high level
7. Are you satisfied with your current HbA1c level?
1Yes
2No
8. Are you satisfied with your current insulin regimen?
1Yes
2No
9. How often have you experienced perceptions oflow blood glucose levels (perceptions of hypoglycaemia) during the past 4 weeks? (please circle one)
00 times
11-2 times
23-4 times
35-6 times
47-8 times
5More than 8 times
10. How often, during the past 4 weeks, have you measured blood glucose values below 3 mmol/l without having felt that you have low blood glucose levels (e.g., asymptomatic low)? (please circle one)
00 times
11-2 times
23-4 times
35-6 times
47-8 times
5More than 8 times
11. Are you afraid of hypoglycaemias?
1Yes
2No
12. Besides diabetes, do you suffer from any other chronic diseases?
1.No
2. Yes, which? ______