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Q1. |
What is your age? |
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Q2. |
Income? |
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Q3. |
Gender? |
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| Q4. |
What is your ethnicity? |
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Q5. |
What level of education did you
complete? |
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Q6. |
What Diabetic condition have
you been diagnosed with? |
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Q7. |
How many years has it been
since you were first diagnosed with a Diabetic Condition? |
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Q8. |
Are you currently taking
medication for Diabetes |
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Q9. |
If yes, what
Diabetic Medication are you currently taking? |
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A) Metformin |
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B) Avandia |
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C) Actos |
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D) Avandamet |
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E) Insulin |
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F) Other |
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Q10. |
Are you
currently taking more than 1 Diabetes Medication? |
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Q11. |
Are you
currently taking medication for high cholesterol? |
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Q12. |
Are you currently taking
medication for high blood pressure? |
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Q13. |
To what extent do you believe
the following statements describe your attitude about managing
your diabetes?
| Does
Not Describe At All |
Completely Describes |
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| |
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| A. |
Managing
Diabetes requires some lifestyle changes. I am
willing to change what I must to succeed in staying
healthy. |
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| B. |
My
doctor says it is manageable and I follow my doctor's
directions. |
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| C. |
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. |
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| D. |
I have
almost lost hope that I can manage my Diabetes. I
take my medications, but I don't see any improvement. |
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Q14. |
To what extend to you believe
that Diabetes has affected your lifestyle?
| |
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| A. |
Motivates me to focus on self-improvement |
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| B. |
Puts me
in a state of depression |
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| C. |
Motivates me to exercise |
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| D. |
Limits
my participation in sports and recreation |
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| E. |
Motivates me to improve my eating habits |
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| F. |
Negatively affects my relationships |
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| G. |
Motivates me to quit smoking |
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| H. |
Restricts my social life |
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Q15. |
To 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 |
|
| |
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| A. |
I am shocked that I have
been diagnosed with Diabetes |
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| B. |
I feel desperate and out of
control dealing with my Diabetes |
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| C. |
Sometimes I am in control
and sometimes my Diabetes is |
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| D. |
I track and monitor my blood
glucose continuously |
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| E. |
I am willing to accept any
help in managing Diabetes |
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F. |
I don't want any help and
will handle this condition myself |
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G. |
I can still eat a lot of the
foods I want to eat |
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H. |
I cut out snacks to stay in
control of my Diabetes |
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Q16. |
To what extent do you believe
that Diabetes is related to each of the following?|
| No
Relation to Diabetes |
High
Relation to Diabetes |
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| |
|
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| A. |
Blindness |
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| B. |
Heart Disease |
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| C. |
Cardiovascular Risk |
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| D. |
Limb Loss |
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| E. |
Blurred Vision |
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F. |
High Cholesterol |
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G. |
Obesity |
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H. |
High Blood Pressure |
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I. |
Heart Attack |
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J. |
Stroke |
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Q17. |
Regarding the Diabetes
medication you are currently taking, how satisfied are you
with each of the following.
| Not
Satisfied At All |
Completely Satisfied |
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| |
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| A. |
Effectiveness |
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| B. |
Safety |
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| C. |
Side Effects |
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| D. |
Convenience |
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Q18. |
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.
| Not At
All Willing |
Very
Willing |
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Q19. |
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?
| Not
At All Motivated |
Highly
Motivated |
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Q20. |
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 agree with each of the
following actions?
| Do Not
Agree At All |
Completely Agree |
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| |
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| A. |
I would more effectively
control my Diabetes |
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| B. |
I would more effectively
control my cholesterol |
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| C. |
I would exercise more |
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| D. |
I would change my diet |
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E. |
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. |
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Q21. |
To what extent do you feel the
following factors would motivate you to ask for the new drug
mentioned in Question #19 above?
| Not
Motivate At All |
Highly
Motivate |
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| |
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| A. |
I want the most advanced
treatment |
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| B. |
I want to feel better |
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| C. |
I want to do the best that I
can under the circumstances |
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| D. |
I don't want to die |
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E. |
My doctor told me about it |
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F. |
I would have to do research
on the drug |
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G. |
I want to live a long life
with my family |
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H. |
I want to go back to before
I had this disease |
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Q22. |
To what extent do the following
factors describe your resistance to trying a new drug?
|
Completely Disagree |
Completely Agree |
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| |
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| A. |
Nothing is going to work |
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| B. |
Every medication has side
effects |
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| C. |
Everything I have tried to
date has not worked |
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| D. |
I'm taking too many drugs
already |
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E. |
Another drug will negatively
interact with my other medications |
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F. |
I don't have enough
information about the new drug |
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G. |
I have other pre-existing
conditions which will get worse if I take more drugs |
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H. |
I worry about the long term
safety of new drugs |
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