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Diabetes + Mental Health Survey
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* Indicates required question
Do you have diabetes or are you a parent of a child living at home?
*
I have diabetes
I am the parent of a child with diabetes.
What type of diabetes do you /your child live with?
*
Type 1
Type 2
LADA
MODY
How old are you?
*
18-25
26-39
40-55
55+
At your last appointment for diabetes (endo, CDE, etc), did your healthcare provider screen your mental health?
*
Yes, I filled out a questionnaire
Yes, they asked me about it directly
No, I was not asked
At your last appointment for diabetes (endo, CDE, etc), did you have a conversation about your mental health?
*
Yes, we talked about it because of the questionnaire
Yes, we talked about it because they asked me about it
Yes, we talked about it because I brought it up
No, we did not talk about it.
In the last 2 weeks, what emotions have you felt in relation to your diabetes? (choose all that apply)
*
Sad
Hopeless
Frustrated
Overwhelmed
Angry
Apathetic
Resentful
Confused
Anxious
Afraid
I did not feel any of these emotions regarding my diabetes in the last 2 weeks
Required
Has your diabetes healthcare provider ever given you the Diabetes Distress Scale questionnaire?
*
Yes
No
No, but I have filled it out on my own
Has your diabetes healthcare provider ever given a referral to a mental health professional?
*
Yes, they gave me a specific name
Yes, but I had to find someone on my own
No, although I think I needed one
No, because I didn't need one
Required
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