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B1
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Who currently provides your main diabetes health care? (Mark one.) |
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B2
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How long have you been seeing the health care provider who takes care of your diabetes? (Mark one.) |
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B3
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When was your last Hemoglobin A1c test? (This is also known as glycohemoglobin or glycosylated hemoglobin, a test that measures your average blood sugar level over the past two or three months.) (Mark one.) |
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B4
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What was the value of your Hemoglobin A1c the last time your health care provider checked it? (Mark one.) |
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B5
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Do you have a goal or target for what you would like your Hemoglobin A1c level to be at or below? |
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B6
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What is your goal for your Hemoglobin A1c level? |
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B7
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My last urine analysis was: (Mark one.) (Gave a urine sample to be tested by the health care provider, clinic, or laboratory) |
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B8
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In the past 12 months, how many times have you stayed overnight in the hospital? (Mark one.) |
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B9A
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In the past 12 months, how many times did you: (Mark one answer for each line.) See the doctor or nurse who takes care of your diabetes |
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B9B
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See any other medical doctor or nurse in a doctor's office or medical clinic |
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B9C
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See any doctor or nurse in an emergency room |
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B10
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When was the last time that you had an eye exam during which the doctor put drops in your eyes that made your pupils large? (You may have been unable to see enough to drive or had to wear dark glasses afterward.) (Mark one.) |
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B11
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Have you ever had diabetes education outside your usual doctor or nurse visits, either individually by a diabetes educator or in a special class? (qxb11) |
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B12
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If you have not had diabetes education, why not? (Mark all that apply.) |
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B13
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Did you ever see a dietitian to learn about a diabetic meal plan or diet? |
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B14
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If you have never seen a dietitian, why not? (Mark all that apply) |
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B15A
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How often do you get any diabetes information from the following sources? Television |
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B15B
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How often do you get any diabetes information from the following sources? Internet |
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B15C
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How often do you get any diabetes information from the following sources? Newspapers or magazines |
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B15D
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How often do you get any diabetes information from the following sources? Books |
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B15E
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How often do you get any diabetes information from the following sources? Friends |
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B16
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How often do you bring up with your doctor any information you've heard or seen that might affect your treatment? (Mark one.) |