Questions | Problem Indicators | |||||
---|---|---|---|---|---|---|
Item non response/ missing | Inadequate answer | Request for clarification | Answer with comments | Do not know | No improvement by probing | |
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 |