Diabetes And Insulin Self-Monitoring Questionnaire Step 1 of 7 14% X/Twitter OptionalThis field is for validation purposes and should be left unchanged.About YouYour Name First Last Date of Birth DD slash MM slash YYYY Contact Phone NumberYour Email Address Enter Email Optional Confirm Email Optional Diabetes and Insulin Self-Monitoring Questions:1. Do you currently check your blood glucose at home? Yes No Thank you, no further questions needed.2. What do you use to monitor your blood glucose? Finger-prick glucose meter Flash / Continuous Glucose Monitor (e.g., Libre, Dexcom) Both Not sure Self-monitoring skills3. How confident do you feel using your glucose meter or sensor? Very confident Mostly confident Not very confident Not confident at all 4. How confident do you feel interpreting the results of your glucose meter or sensor? Very confident Mostly confident Not very confident Not confident at all Eg: do you know the ranges for normal blood glucose measurements and how these changes after meals / medication?5. Do you feel you would benefit from extra support or training with your glucose meter/sensor? Yes No Quality and Frequency of Testing6. How often do you usually check your blood glucose? 4 times or more per day At least once per day Few days per week Less than once per week I do not currently test 7. Do you experience problems with your glucose meter/sensor readings? Often Sometimes Rarely Never If you answered “often” or “sometimes”, please describe the issue: Optional 8. Do you feel confident knowing when your blood glucose is high? Yes Sometimes No 9. Do you feel confident knowing when your blood glucose is low (“hypo”)? Yes No 10. Have you had any episodes of low blood sugar (“hypos”) in the past 12 months? Yes No Not Sure Did you need help from someone else during your low blood sugar episode? Yes No Impact on Quality of Life11. Does checking your blood glucose affect your daily life (e.g., stress, routine, work, sleep)? Not at all A little Quite a lot All the time Please tell us how it affects your daily life: Optional Continued Benefit to PatientWould you be interested in reviewing how you use your glucose readings (e.g., adjusting insulin safely, spotting patterns)? Yes No Equipment Check13. Is your meter/sensor working reliably? Yes Sometimes faulty Often faulty Not sure 14. When did you last replace your strips/sensors/lancets? Less than 1 month ago 1–3 months ago More than 3 months ago Not sure 15. Do you have enough test strips/sensors/lancets? Yes No Sometimes I run out
