1. In the last 6 months, have you seen your primary care physician or have you had to ask for a house call? If Yes, please specify the number of contacts?
|
18
|
19
|
9
|
8
|
6
|
11
|
2. In the last 6 months, have you visited the emergency room or a medical emergency service or something similar due to an emergency? If Yes, please specify the number of contacts?
|
2
|
14
|
1
|
1
|
0
|
3
|
3. In the last 6 months, have you seen any of the following physicians having their own practice (a list provided)? If Yes, please specify the number of contacts?
|
10
|
13
|
7
|
2
|
2
|
5
|
4. Please provide an estimate of how much time you have spent on all your outpatient doctor visits in the last 6 months. Please also consider travel time to and from physicians and time spent waiting.
|
16
|
4
|
5
|
10
|
8
|
17
|
5. In the last 6 months, have you had any of the following special medical tests (a list provided)? Please check all that apply. If Yes, please specify how many times?
|
8
|
3
|
2
|
4
|
3
|
3
|
6. In the last 6 months, have you gone to see a physical therapist, naturopath, or other therapists (a list provided)? If Yes, please specify the number of contacts.
|
2
|
8
|
1
|
4
|
0
|
1
|
7. In the last 6 months, have there been any treatment changes with regard to your diabetes treatment? If Yes, please check all that apply (for each treatment a list of possible changes, i.e. newly prescribed, discontinued, dose reduced, dose increased was provided and participants were asked when the changes occurred).
|
5
|
10
|
4
|
5
|
1
|
0
|
8. If you are treated with blood-sugar lowering tablets at present, please provide the exact medication name and the daily dose.
|
9
|
3
|
1
|
0
|
1
|
4
|
9. If you are treated with insulin at present, please indicate how you administer insulin, the exact insulin product name and units per day.
|
7
|
1
|
1
|
1
|
0
|
1
|
10. Please indicate which medications you REGULARLY take in addition to your diabetes therapy at present. Please specify exact medication name, form of administration (tablets, liquid, etc.) and daily dose.
|
21
|
12
|
7
|
3
|
5
|
15
|
11. Are there any other medications that you have been taking AS NEEDED in the last 6 months? If Yes, please specify exact medication name, form of administration (tablets, liquid, etc.), daily dose and frequency of use in the last 6 months.
|
11
|
3
|
1
|
1
|
1
|
8
|
12. In the last 6 months, how much have you paid for all of your medications (including expenses for prescription fees)? If you are not able to indicate the exact amount, please provide an estimate. |
14 |
10 |
10 |
11 |
8 |
18 |