Step 2: Help Us Understand You Better
The following items help us better understand the people we serve. You do not have to answer these items for us to answer your question, but we hope that you will. This information will be collated and may be published on our website periodically, or may be used for publication, but we will use composite data only. We do not maintain any individual data from these items. If you ask another question at a later time, please fill this out each time.
For whom are you asking this question?
Please select
Myself
My child
My grandchild
My spouse or partner
My parent
Another relative
A friend
My girlfriend or boyfriend
My patient
Other
The age of the person in question is:
Please select
Under two years old
Between 2 and 5 years old
Between 6 and 12 years old
Between 13 and 18 years old
Between 19 and 40 years old
Between 41 and 60 years old
Over 60 years old
The person in question has:
Please select
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Other diagnosed diabetes
Diabetes, suspected
Hypoglycemia, diagnosed
Hypoglycemia, suspected
PCOS
Don't know
Other illness
The person in question has had diabetes for:
Please select
Less than six months
Less than one year
Less than two years
Less than five years
Less than 10 years
10 years or more
Doesn't apply
Don't know
The treatment plan of the person in question is:
Please select
Takes insulin injections
Uses an insulin pump
Takes oral diabetes medications
Takes insulin and oral medications
Uses diet and exercise only
Has diabetes but doesn't take any medications
Has diabetes but doesn't have a treatment plan
Doesn't apply
Other
What kind of insurance coverage does the person have?
Please select
Private insurance through an employer
Private insurance that I/my parents pay for
Medicare/Medicaid/other US/state funded plan
National health care outside the US
Self-insured
Uninsured
Don't Know
Other
Medical care about blood sugar problems is provided by:
Please select
A general practice or family practice doctor
A general pediatrician
A general internal medicine physician
Another doctor plus an endocrinologist or diabetes specialist
An endocrinologist or diabetes specialist only
A nurse practitioner or physician assistant working for a general physician
A nurse practitioner or physician assistant working for an endo or diabetes specialist
Another health professional
No health professional at the present time
Don't know
Other
You are asking this question because:
Please select
I need a second opinion
The doctor or diabetes team didn't give me the answer I wanted
I'm not comfortable asking this of the doctor
I want to know this before I talk to the doctor
I don't have a doctor
Other