Diabetes Survey November 24, 2014 By canadianesurvey Name First Last Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country AgeGender Male Female Household Income0 - $15K$16K - $25K$26k - $50K$51K - $100K$101K - $200K$201K +Number of children0123456+What is your ethinicity?Native AmericanWhiteAfrican AmericanHispanicAsianOtherWhat level of education did you complete?Some High SchoolHigh SchoolSome CollegeCollege or HigherWhat diabetic condition have you been diagnosed with?Pre-DiabetesType IType IIHow many years has it been since you were first diagnosed with a Diabetic Condition?123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899Are you currently taking medication for DiabetesYesNoIf yes, what Diabetic Medication are you currently taking? Metformin Avandia Lantus Actos Avandamet Insulin Januvia Other Other medication:Are you currently taking more than 1 Diabetes Medication?YesNoAre you currently taking medication for high cholesterol?YesNoAre you currently taking medication for high blood pressure?YesNoTo what extent do you believe the following statements describe your attitude about managing your diabetes? Does Not Describe At All Completely Describes A. Managing Diabetes requires some lifestyle changes. I am willing to change what I must to succeed in staying healthy.12345678910B. My doctor says it is manageable and I follow my doctor's directions.12345678910C. Look, I am taking medication, but who knows if it is working. I know I should lose weight and exercise, but it is so hard.12345678910D. I have almost lost hope that I can manage my Diabetes. I take my medications, but I don't see any improvement.12345678910To what extend to you believe that Diabetes has affected your lifestyle? Not At All Completely A. Motivates me to focus on self-improvement12345678910B. Puts me in a state of depression12345678910C. Motivates me to exercise12345678910D. Limits my participation in sports and recreation12345678910E. Motivates me to improve my eating habits12345678910F. Negatively affects my relationships12345678910G. Motivates me to quit smoking12345678910H. Restricts my social life12345678910To what extent would you agree with each of the following statements regarding how you feel about living with Diabetes. Do Not Agree At All Completely Agree A. I am shocked that I have been diagnosed with Diabetes12345678910B. I feel desperate and out of control dealing with my Diabetes12345678910C. Sometimes I am in control and sometimes my Diabetes is12345678910D. I track and monitor my blood glucose continuously12345678910E. I am willing to accept any help in managing Diabetes12345678910F. I don't want any help and will handle this condition myself12345678910G. I can still eat a lot of the foods I want to eat12345678910H. I cut out snacks to stay in control of my Diabetes12345678910To what extent do you believe that Diabetes is related to each of the following? No Relation to Diabetes High Relation to Diabetes A. Blindness12345678910B. Heart Disease12345678910C. Cardiovascular Risk12345678910D. Limb Loss12345678910E. Blurred Vision12345678910F. High Cholesterol12345678910G. Obesity12345678910H. High Blood Pressure12345678910I. Heart Attack12345678910J. Stroke12345678910Regarding the Diabetes medication you are currently taking, how satisfied are you with each of the following. Not Satisfied At All Completely Satisfied A. Effectiveness12345678910B. Safety12345678910C. Side Effects12345678910D. Convenience12345678910 Not At All Willing Very Willing If you are not satisfied with your current medication, how willing would you be to ask your doctor about a new class of Diabetes medication.12345678910 Not At All Motivated Highly Motivated If you were to understand that heart disease is one of the most serious diabetes complications, accounting for the majority of Diabetes related deaths, to what extent would you be more or less motivated to ask your doctor about a new class of Diabetes medication with unique cardiovascular benefits?12345678910Regarding the Diabetes medication you are currently taking, how satisfied are you with each of the following. Do Not Agree At All Completely Agree A. I would more effectively control my Diabetes12345678910B. I would more effectively control my cholesterol12345678910C. I would exercise more12345678910D. I would change my diet12345678910E. I would make no changes in my Diabetes control regimen. I am only concerned about Diabetes. I do not believe that I am at risk for heart disease.12345678910To what extent do you feel the following factors would motivate you to ask for the new drug mentioned in Question #19 above? Not Motivated At All Highly Motivated A. I want the most advanced treatment12345678910B. I want to feel better12345678910C. I want to do the best that I can under the circumstances12345678910D. I don't want to die12345678910E. My doctor told me about it12345678910F. I would have to do research on the drug12345678910G. I want to live a long life with my family12345678910H. I want to go back to before I had this disease12345678910To what extent do the following factors describe your resistance to trying a new drug? Completely Disagree Completely Agree A. Nothing is going to work12345678910B. Every medication has side effects12345678910C. Everything I have tried to date has not worked12345678910D. I'm taking too many drugs already12345678910E. Another drug will negatively interact with my other medications12345678910F. I don't have enough information about the new drug12345678910G. I have other pre-existing conditions which will get worse if I take more drugs12345678910H. I worry about the long term safety of new drugs12345678910 Δ To Top