Diabetes Survey Tool

DIRECTIONS: Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Consider the degree to which each of the items may have distressed or bothered you DURING THE PAST MONTH and select the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would select "1". If it is very bothersome to you, you might select "6".

1. Feeling that diabetes is taking up too much of my mental and physical energy everyday.

2. Feeling that my doctor doesn't know enough about diabetes and diabetes care.

3. Not feeling confident in my day-to-day ability to manage diabetes.

4. Feeling angry, scared, and/or depressed when I think about living with diabetes.

5. Feeling that my doctor doesn't give me clear enough directions on how to manage my diabetes.

6. Feeling that I am not testing my blood sugars frequently enough.

7. Feeling that I will end up with serious long-term complications, no matter what I do.

8. Feeling that I am often failing with my diabetes routine.

9. Feeling that friends or family are not supportive enough of self-care efforts (e.g. planning activities that conflict with my schedule, encouraging me to eat the "wrong" foods).

10. Feeling that diabetes controls my life.

11. Feeling that my doctor doesn't take my concerns seriously enough.

12. Feeling that I am not sticking closely enough to a good meal plan.

13. Feeling that friends or family don't appreciate how difficult living with diabetes can be.

14. Feeling overwhelmed by the demands of living with diabetes.

15. Feeling that I don't have a doctor who I can see regularly enough about my diabetes.

16. Not feeling motivated to keep up my diabetes self management.

17. Feeling that friends or family don't give me the emotional support that I would like.

Patient's NRIC – last 4 characters (eg. 567A)

Patient's Date of Birth

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