children with DIABETES - CWD Survey for Andrea Steiner

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		CWD Survey for Andrea Steiner

As of Monday, January 19, 2004, this survey is closed.

My name is Andrea Steiner, and I am currently a high school senior. My career goal is to become a Pediatric Nurse. I was diagnosed with Juvenile diabetes when I was four years old and I am deaf in one ear.

I am conducting a research project for those with Type 1 diabetes that have received the MMR shot prior to their diagnosis. I am also interested in possible further complications following their diagnosis with diabetes. I am collecting this data for a research project for the Young Epidemiology Scholars Program. Thank you for completing this brief survey.

1. Did you receive the Measles/Mumps/Rubella shot (MMR) before being diagnosed with diabetes?
Yes
No
I don't know

2. If applicable, how long had you taken the MMR before being diagnosed with Type 1 diabetes?

weeks

months

years

unknown
not applicable

3. Do you have any of the following disorders? (Please check all that apply)
Deafness in one or both ears
Behavioral/learning problems
Epilepsy
Arthritis
Meningitis (or other forms of brain damage)
Autism
Bowel Problems
Other

4. Were other infections present before being diagnosed with Type 1 diabetes? If Yes, what?
Yes
No
I don't know

5. Do you have a history of Type 1 diabetes in your family?
Yes
No

If yes:

How many people in your family are diagnosed?

Did they receive the MMR shot?

Do they have any other disorders? (please list)

6. Do you have a history of Type 2 diabetes in your family?
Yes
No
I don't know

7. Where are you from?

City

State

Country

8. At what age were you diagnosed with diabetes?
0 to 4 years
4 to 8 years
8 to 12 years
12 years or older

9. How many children are in your family and where are you in the birth order?

I am the child of

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Last Updated: Monday January 19, 2004 15:20:59
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How many people in your family are diagnosed?
Did they receive the MMR shot?
Do they have any other disorders? (please list)