Name of the patient *

Name of the referring Doctor

Contact Number of Patient / Referring Doctor *

Email Address

Date of Birth of Patient *

Mention about your diagnosis and duration

1. Feeling that I am not as skilled at managing diabetes as I should be. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

3. Feeling that I don’t notice the warning signs of hypoglycemia as well as I used to. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

4. Feeling that people treat me differently when they find out I have diabetes *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

5. Feeling discouraged when I see high blood glucose numbers that I can’t explain. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

6. Feeling that my family and friends make a bigger deal out of diabetes than they should. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

7. Feeling that I can’t tell my diabetes doctor what is really on my mind. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

9. Feeling that there is too much diabetes equipment and stuff I must always have with me. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

11. Feeling that my friends and family worry more about hypoglycemia than I want them to. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

12. Feeling that I don’t check my blood glucose level as often as I probably should. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

13. Feeling worried that I will develop serious long-‐term complications, no matter how hard I try. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

14. Feeling that I don’t get help I really need from my diabetes doctor about managing diabetes. *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

15. Feeling frightened that I could have a serious hypoglycemic event when I’m asleep *Not a problemA slight problemA moderate problemA somewhat serious problemA serious problemA very serious problem

Type 1 Diabetes Impact

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Type 1 Diabetes Impact

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