Questionnaire on Awareness of Diabetes Mellitus

Dr. Kanak Choudhury

S. No.: _________
Age: _____yrs Weight: ______ kg BP:_____
Sex: Male/Female/Others Height: _______ m PR:_____
Education: BMI: _______kg/m2
Occupation:
1. Are you aware of a condition called Diabetes? Yes/No
2. If Yes, how you came to know?
 Newspaper
 Television
 Peers, Relatives
 Physician
 I’m a Diabetic
 Others. Specify_________
3. What do you know about Diabetes?
 It’s a metabolic disorder
 It’s a chronic disease
 It is curable
 It is communicable
 It is non-communicable
 There is high blood sugar level
 It causes damages to organs
 Others. Specify ___________
4. Are you a Diabetic? Yes/No Skip to 12 if No
5. If Yes, how were you diagnosed?
 Opportunistic screening
 Routine check-up
 Acute attack
 Others
6. Are you on any medication for Diabetes? Yes/No
7. If Yes, which drug are you taking?
 Insulin
 Oral hypoglycaemic agents
 Others. Specify________
8. Are you maintaining routine follow-up? Yes/No
9. Are you aware of the complications of diabetes? Yes/No
10. Are you having any complication? Yes/No
 Questionnaire on Awareness of Diabetes Mellitus

Dr. Kanak Choudhury

11. If Yes, what complications are you having?

 Impaired vision
 Kidney disease
 Nerve disorder
 Heart disease
 Diabetic foot
 Stroke
 Others. Specify ________
12. Do you think family history is important in Diabetes? Yes/No
13. Is there any Diabetic patient in your family? Yes/No
14. Do you think lifestyle has got a relation with Diabetes? Yes/No
15. Do you do daily exercise? Yes/No
16. If Yes, what sort of exercise do you do?
 Running
 Jogging
 Gymnasium
 Office work
 Others. Specify _________
17. Do you think alcohol intake has got a role in Diabetes? Yes/No
18. Do you intake alcohol? Yes/No
19. If Yes, how much per week?
 1 peg
 2 -5 pegs
 6-10 pegs
 >10 pegs
20. Are you aware of the harmful effects of alcohol intake? Yes/No
21. Do you think smoking has got a relation with Diabetes? Yes/No
22. Do you smoke? Yes/No
23. If Yes, how many cigarettes per day?
 <1 pack
 1 pack
 2 packs
 >2 packs
24. Are you aware of the harmful effects of smoking? Yes/No
25. Do you think change in diet has got a positive role in control of Diabetes? Yes/No
26. Are you having any sort of stress or depression? Yes/No
27. Do you think change in lifestyle has got a positive role in control of Diabetes? Yes/No
28. Do you think Diabetes is curable? Yes/No
29. Are you aware of the complications of diabetes? Yes/No
 Questionnaire on Awareness of Diabetes Mellitus

Dr. Kanak Choudhury

30. If Yes, what complications may arise?

 Impaired vision
 Skin disease
 Kidney disease
 Nerve disorder
 Heart disease
 Diabetic foot
 Lung disease
 Stroke
 Others. Specify ________
31. Do you think surveys like this should be done? Yes/No