1.

Problems	Not a Problem		Moderate Problem		Serious Problem		Office Use Only
1. Feeling that diabetes is taking up too much of my mental and physical energy every day.	1	2	3	4	5	6	[A]
2. Feeling that my doctor doesn’t know enough about diabetes and diabetes care.	1	2	3	4	5	6	[B]
3. Feeling angry, scared and/or depressed when I think about living with diabetes.	1	2	3	4	5	6	[A]
4. Feeling that my doctor doesn’t give me clear enough directions on how to man- age my diabetes.	1	2	3	4	5	6	[B]
5. Feeling that I am not testing my blood sugars frequently enough.	1	2	3	4	5	6	[C]
6. Feeling that I am often failing with my diabetes regimen.	1	2	3	4	5	6	[C]
7. Feeling that friends or family are not supportive enough of my self-care efforts (eg planning activities that conflict with my schedule, encouraging me to eat the “wrong” foods).	1	2	3	4	5	6	[D]
8. Feeling that diabetes controls my life.	1	2	3	4	5	6	[A]
9. Feeling that my doctor doesn’t take my concerns seriously enough.	1	2	3	4	5	6	[B]
10. Not feeling confident in my day-to-day ability to manage diabetes.	1	2	3	4	5	6	[C]
11. Feeling that I will end up with serious long-term complications, no matter what I do.	1	2	3	4	5	6	[A]
12. Feeling that I am not sticking closely enough to a good meal plan.	1	2	3	4	5	6	[C]
13. Feeling that friends or family don’t appreciate how difficult living with diabetes can be.	1	2	3	4	5	6	[D]
14. Feeling overwhelmed by the demands of living with diabetes.	1	2	3	4	5	6	[A]
15. Feeling that I don’t have a doctor who I can see regularly about my diabetes.	1	2	3	4	5	6	[B]
16. Not feeling motivated to keep up my diabetes self-management.	1	2	3	4	5	6	[C]
17. Feeling that friends or family don’t give me the emotional support that I would like.	1	2	3	4	5	6	[D]