Transcription of Diabetes Self-Management Questionnaire
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Diabetes Self-Management Questionnaire
Diabetes Self-Management Questionnaire Page 1 REVISED 10/23/13 Diabetes Self-Management Questionnaire General Information 1. Name: _____ Age: _____ Date: _____ 2. Address: _____City: _____ Zip Code: _____ 3. Home phone: _____ Work phone: _____ Cell: _____ 4. Your primary physician s name:_____ 5. Your Diabetes physician s name: _____ 6. What is your race or ethnic background? American Indian or Alaskan Native Asian/Chinese/Japanese/Korean Black/African American Hispanic/Latino/Mexican White/Caucasian Native Hawaiian or other Pacific Islander Other: _____ Socioeconomic/ Support System 1. Marital status: Single Married Divorced Widowed 2. How many people live in your household? _____ 3. Does anyone else who lives with you have Diabetes ? No Yes (Who?): _____ 4.
Diabetes Self-Management Questionnaire Page 6 REVISED 10/23/13 4. If you take insulin: Do you inject insulin with: ¨ Syringe ¨ Insulin pen ¨ Insulin pump
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