Download:
pdf |
pdf 3. Has a doctor ever told you or your child that he/she has high blood pressure?
1
Yes
3a. If yes, has a doctor ever prescribed any medicine for high blood pressure?
1
Yes
2
No
3
Don’t know
3b. Is your child now taking any medicine for high blood pressure?
1
2
No
3
Don’t know
Yes
2
No
3
Don’t know
4. Has a doctor ever told you or your child that he/she had any of the following?
1
Yes
2
No
Addison’s Disease
1
Yes
2
No
Asthma
1
Yes
2
No
Celiac disease
1
Yes
2
No
Hyperthyroidism (high thyroid)
1
Yes
2
No
Hypothyroidism (low thyroid)
1
Yes
2
No
Vitiligo (white skin patches)
5. Has a doctor said that diabetes has affected your child’s kidneys?
1
Yes
2
No
3
Don’t know
6. Has a doctor said that diabetes has damaged the back of your child’s eyes, that is, the retina?
1
Yes
6a. If yes, did this require laser treatment of the retina?
2
No
3
Don’t know
1
Yes
2
No
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7. Has your child had any other major illness or medical conditions that we have not asked about?
1
Yes
2
No
If yes, please describe:
Questions 8 and 9 are for FEMALES only.
8. Has your child already had her first period?
1
8a. If yes, how old was your child when she had her
first period?
Yes
1
2
No
3
Don’t know
years old
Don’t know
9. Has a doctor ever told you or your child that your child has polycystic ovaries (PCO, PCOS)?
1
Yes
2
No
3
Don’t know
MEDICAL HISTORY
The next few questions are about emergency room and hospital visits your child may have had.
10. In the last 6 months, has your child been to the emergency room for any reason?
1
Yes
2
No
10a. How many times was your child in the emergency room?
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# of times
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11. In the last 6 months, has your child had one or more night’s hospital stay for any reason?
1
Yes
2
No
11a. How many times was your child in the
hospital for one or more nights?
# of times
12. In the past 6 months, has your child had any severe hypoglycemia, that is, very low blood sugar that
required him/her to get help?
1
2
Yes
12a. How many times?
# of times
12b. How many times was your child given an
injection of glucagon – for hypoglycemia (low
blood sugar)?
# of times
12c. How many times was “911” or life squad/
paramedics called for hypoglycemia?
# of times
12d. How many times did your child go to an
emergency room for hypoglycemia?
# of times
12e. How many times did your child need to stay
overnight at a hospital?
# of times
No
13. In the past 6 months, has your child had ketoacidosis (often called DKA, frequently with high blood sugar,
vomiting and shortness of breath)?
1
Yes
13a. How many times?
13b. How many times did this result in an
emergency room visit?
13c. How many times did this result in one or more
night’s hospital stay?
2
# of times
# of times
# of times
No
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MEDICATION INVENTORY
Insulin Use
14. Was your child ever treated with insulin (shots/pumps) since he/she was diagnosed?
1
No (skip to question 20)
2
Yes
15. If yes, when were insulin shots/pump started?
1
At diagnosis
2
Less than 1 month after diagnosis
3
Within 1-6 months after diagnosis
4
Within 6-12 months after diagnosis
5
1 year or more after diagnosis
16. Did your child ever stop taking insulin?
1
No (skip to question 20)
2
Yes
17. If yes, did that happen…
1
Less than 1st month after diagnosis
2
1-6 months after diagnosis
3
6-12 months after diagnosis
4
1 year or more after diagnosis
18. How long was your child off insulin?
1
Less than 1 month
2
1-6 months
3
6-12 months
4
1 year or more
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19. Did your child ever have any episodes of ketoacidosis (DKA) when insulin was stopped?
Yes
2 No
3 Don’t know
1
20. How does your child currently treat his/her diabetes? Does your child use: (check yes or no for each)
20a. Diabetes tablets (pills)
1
Yes
2
No
20b. Insulin shots, pump, or pen
1
Yes
2
No
20c. Diet (meal plan)
1
Yes
2
No
20d. Exercise
1
Yes
2
No
20e. Other (what?)
21. If your child is currently taking insulin, how often does he/she take insulin each day on average? (if your
child is not currently taking insulin, go to question 24)
1
1 time a day
4
More than 3 times a day
2
2 times a day
5
Insulin pump
3
3 times a day
22. How does your child take insulin?
1
22a. With a syringe (needle)
2
22b. With an insulin pump
3
22c. With an insulin pen
Worksheet
23. What was the dose of insulin (number of units) that your child
took yesterday. (If your child uses an insulin pump, record
the bolus amounts in 23a – 23e, and record the total 24-hour
basal dose in 23f. This may require filling out a worksheet of
hourly basal rates to determine the total basal dose.)
23a.
Breakfast
.
23b.
Lunch
.
23c.
Dinner
.
23d.
Bedtime
.
23e.
Other
23f.
Pump
.
.
Total insulin:
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Is your child under ten years of age?
Yes (If Yes, continue to Question 24)
No (If No, skip to question 26)
24. How often did your child miss his/her diabetes medicine including insulin?
1
Doesn’t take diabetes medicine
2
Never
3
1-3 times a month
4
1-5 times a week
5
1 time a day
6
More than 1 time a day
(skip to question 26)
(skip to question 26)
25. Check Yes, No, or Not applicable. When your child misses a diabetes medicine is it because:
Yes
2
No
3
Not applicable
Forgot
Yes
2
No
3
Not applicable
Thought it would help to lose weight
Yes
2
No
3
Not applicable
Worried about low blood sugar
Yes
2
No
3
Not applicable
Cannot afford insulin supplies or other medicine
Yes
2
No
3
Not applicable
Don’t want to give insulin when others are around
Yes
2
No
3
Not applicable
Tired of shots
Yes
2
No
3
Not applicable
Afraid of needles
Yes
2
No
3
Not applicable
Other reason (specify)
25a.
1
25b.
1
25c.
1
25d.
1
25e.
1
25f.
1
25g.
1
25h.
1
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Prescribed Medications
26. Is your child taking prescribed medication(s) including insulin?
1
2
Yes (If Yes, document up to 10 medications below. If your child is taking insulin, be certain to include all
No (if No, skip to question 27)
types or preparations.)
1.
______________________________________________
2.
______________________________________________
3.
______________________________________________
4.
______________________________________________
5.
______________________________________________
6.
______________________________________________
7.
______________________________________________
8.
______________________________________________
9.
______________________________________________
10.
______________________________________________
Diabetes Education
The next few questions are about what you have been taught about diabetes.
27. In the past 12 months have you met with a diabetes
nurse or diabetes educator?
1
Yes
2
No
3
Don’t know
28. In the past 12 months have you met with a dietician or nutritionist, or talked to someone in detail about
your child’s diet?
1
2
Yes
28a. When he/she was staying one or
more nights in the hospital
1
Yes
2
No
3
Don’t know
28b. As an outpatient
1
Yes
2
No
3
Don’t know
No
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29. In the past 12 months, which of the following types of diabetes information have you received from your
child’s doctor’s office or health care plan? (Check all that apply)
1
Information about diabetes camp
1
Information about diabetes support groups
1
Written materials about diabetes such as pamphlets or newsletters
1
Videos or audio tapes
1
Reminder about upcoming appointments
1
A copy or explanation of diabetes laboratory or test results
1
Diabetes information or advice by telephone
1
Diabetes information or advice in person
1
How to get diabetes information on the internet
1
Information about diabetes research studies other than this study
Below are some questions about your child’s diabetes care and diabetes control.
“Doctor”, is a doctor or
any other health care provider such as a nurse.
30. How would you rate your child’s diabetes care overall: Would you say:
Excellent
2 Good
3 Fair
4 Poor
1
31. How would you rate: (check the appropriate boxes)
Excellent
Good
Fair
Poor
Not applicable
Diabetes care from the doctor
1
2
3
4
5
Getting answers to your diabetes questions
1
2
3
4
5
Access during emergencies
1
2
3
4
5
Getting explanation of lab results
1
2
3
4
5
Courtesy/personal communication style of
your doctor
1
2
3
4
5
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32. How would you rate your child’s diabetes control: Would you say:
Excellent
2 Good
3 Fair
4 Needs much work
1
Home Diabetes Care
Here are some questions about your child’s diabetes care outside of the doctor’s office.
33. Does your child live or stay in more than one home on a regular basis? For example, if the child’s parents
are separated, this would include spending the weekend with the child’s other parent. It would also
include other relatives that your child might live or stay with on a regular basis (at least once per month).
1
2
Yes
33a. If yes, does he/she live in:
1
2 households
2
3 or more households
3
Don’t know
No, live in one household
34. How much of your child’s diabetes care does your child do for him/herself? Would you say: (check one)
None
2 Less than 25%
3 25-75%
4 More than 75%
5 All (skip to question 36)
1
35. Who helps your child with his/her diabetes care?
35a. Parent/step parent/guardian
1
Yes
2
No
35b. Grandparent
1
Yes
2
No
35c. Brother/sister
1
Yes
2
No
35d. Another person
1
Yes
2
No
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36. Is your child’s blood sugar tested at home or any place other than the doctor’s office?
1
Yes
36a. How often is your child’s blood sugar checked with a glucose meter (glucometer)? (check one)
No (if
no, go to
question 37)
Less than once a week
2 Less than once a day
3 1-2 times a day
4 3 times a day
5 4-6 times a day
6 7 or more times a day
7 Only when you are sick
2
1
36b. Does your child use a continuous glucose monitor (CGM) to measure his/her glucose?
Yes
2 No (if no go to 36c)
1
36b(1). If yes, how does he/she use the CGM?
1
He/she has used it through his/her doctor’s office
How often has
he/she used it?
2
1 time
2 2 or more times
3 Don’t know/not sure
1
My child has a CGM for use at home
How often does your child use it?
Rarely/never (0-19% of the time)
Occasionally (20-39% of the time)
3 About half the time (40-59% of the time)
4 Usually (60-79% of the time)
5 Most of the time (80-99% of the time)
6 Always (100% of the time)
7 Don’t know/not sure
1
2
36c. What do you usually do when the blood sugar test results are running too high or too low?
36c(1). Make changes to the diabetes treatment (insulin dose
or other medications, diet or exercise
1
Yes
2
No
36c(2). Call his/her diabetes doctor
1
Yes
2
No
36c(3). Talk to his/her diabetes doctor at the next visit
1
Yes
2
No
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Provider Care
These questions are about the doctors or health care providers that your child sees.
37. Who does your child usually see for his/her diabetes care? (Check only one response)
2
3
4
5
6
7
8
9
10
1
11
13
12
Pediatric endocrinologist/diabetologist (diabetes specialist)
Pediatrician
Family practice doctor
General practice doctor
Adult endocrinologist/diabetologist (diabetes specialist)
Internist
Nurse practitioner/physician’s assistant
Nurse diabetes educator
Traditional medicine man, healer, or curandero/curandera
Dietician/Nutritionist
Other (specify)
Don’t know/unsure of what kind of doctor
None/no source of medical care
38. Who does your child usually see for his/her medical needs not related to diabetes? (Check only one response)
2
3
4
5
6
7
8
9
10
11
12
13
1
Pediatric endocrinologist/diabetologist (diabetes specialist)
Pediatrician
Family practice doctor
General practice doctor
Adult endocrinologist/diabetologist (diabetes specialist)
Internist
Nurse practitioner/physician’s assistant
Nurse diabetes educator
Traditional medicine man, healer, or curandero/curandera
Dietician/Nutritionist
Other (specify)
Don’t know/unsure of what kind of doctor
None/no source of medical care
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Here are questions regarding how often your child sees various medical providers.
39. Who provides medical care for your child? (For each provider checked, indicate the number of visits your
child had with this provider in the past 6 months)
39a.
1
Yes
2
No
Pediatric endocrinologist/
diabetologist (diabetes specialist)
# of visits in the
last 6 months
39b.
1
Yes
2
No
Pediatrician
# of visits in the
last 6 months
39c.
1
Yes
2
No
Family practice doctor
# of visits in the
last 6 months
39d.
1
Yes
2
No
General practice doctor
# of visits in the
last 6 months
39e.
1
Yes
2
No
Adult endocrinologist/
diabetologist (diabetes specialist)
# of visits in the
last 6 months
39f.
1
Yes
2
No
Internist
# of visits in the
last 6 months
39g.
1
Yes
2
No
Nurse practitioner/physician’s
assistant
# of visits in the
last 6 months
39h.
1
Yes
2
No
Nurse diabetes educator
# of visits in the
last 6 months
39i.
1
Yes
2
No
Traditional medicine man, healer,
or curandero/curandera
# of visits in the
last 6 months
39j.
1
Yes
2
No
Dietician
# of visits in the
last 6 months
39k.
1
Yes
2
No
Eye doctor (optometrist,
ophthalmologist)
39l.
1
Yes
2
No
Psychiatrist, psychologist, or
mental health counselor
39m.
1
Yes
2
No
Other
(specify)
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# of visits in the
last 6 months
# of visits in the
last 6 months
# of visits in the
last 6 months
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Insurance and Cost of Diabetes Supplies
40. What kind of health insurance or health care plan does your child have? (check yes, no or don’t know for
each one)
40a. Medicaid/Medicare/State-funded/ other Federally-funded
1
Yes
2
No
40b. Private insurance, through employer
1
Yes
2
No
40c. Private insurance, purchased on your own
1
Yes
2
No
40d. Military
1
Yes
2
No
40e. School-based insurance
1
Yes
2
No
40f. Tribe/Indian Health Service
1
Yes
2
No
40g. Any other or type unknown
1
Yes
2
No
40h. None (if none, go to question 42)
1
Yes
2
No
41. Does your child’s health insurance or health care plan pay for any of his/her… (check yes, no or don’t know for
each one)
41a. Diabetes medicine/insulin
1
Yes
2
No
3
Don’t know
41b. Syringes/pens/needles
1
Yes
2
No
3
Don’t know
41c. Insulin pump and supplies
1
Yes
2
No
3
Don’t know
41d. Home glucose monitor
1
Yes
2
No
3
Don’t know
41e. Monitor strips and related supplies
1
Yes
2
No
3
Don’t know
41f. Diabetes education
1
Yes
2
No
3
Don’t know
41g.
Not applicable
42. About how much do you spend, on average, in a typical month on diabetes medicine and supplies? (This
does not include costs that are covered or later reimbursed by your child’s insurance plan).
1
$0 (none)
2
$1 - $19
3
$20 - $49
4
$50 - $99
5
$100 - $199
6
$200 or more
7
Don’t know
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43. How satisfied are you with your child’s current insurance coverage? Would you say:
1
Very satisfied
2
Satisfied
3
Somewhat satisfied
4
Not satisfied
44. Has your child’s main health insurance plan changed in the last 6 months?
1
Yes (if yes, go to question 44a)
2
No (if no, go to question 45)
Don’t know
4 Don’t want to answer
3
44a. What were the reasons your child’s health insurance plan changed? (check all that apply)
1
Employer stopped offering this plan
1
Doctor left this plan
1
Unhappy with benefits/coverage
1
Too difficult to get care
1
Moved
1
Change in jobs
1
Other
1
Don’t know
1
Don’t want to answer
(specify)
45. Has your child’s main diabetes provider changed in the last six months?
1
Yes (if yes, go to question 45a)
2
No (if no, go to question 46)
3
Don’t know
4
Don’t want to answer
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What were the reasons your child had a change in diabetes provider? (check all that apply)
45a.
1
No longer covered by health plan
Too difficult to get care
1 Not satisfied with care
1 Moved
1 Other (specify)
1
1
Don’t know
1
Don’t want to answer
These questions deal with education and household income. Please remember that your
answers are confidential.
46. What is the highest degree or level of school you have COMPLETED?
No schooling completed
th
2 Nursery school to 4 grade
th
th
3 5 grade or 6 grade
th
th
4 7 grade or 8 grade
th
5 9 grade
th
6 10 grade
th
7 11 grade
th
8 12 grade, NO DIPLOMA
9 High school graduate (high school diploma) or equivalent (for example: GED)
10 Business/technical school
11 Some college credit but less than 1 year
12 1 or more years of college, no degree
13 Associate degree (for example: AA, AS) (2-year)
14 Bachelor’s degree (for example: BA, AB, BS) (4-year)
15 Master’s degree (for example: MA, MS, MEng, MEd, MSW)
1
Professional or doctorate degree (for example: MD, DDS, JD, PhD, EdD)
17 Don’t know
16
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47. What is the highest degree or level of school your current spouse/partner has COMPLETED?
1
No schooling completed
2
Nursery school to 4th grade
3
5th grade or 6th grade
4
7th grade or 8th grade
5
9th grade
6
10th grade
7
11th grade
8
12th grade, NO DIPLOMA
9
High school graduate (high school diploma) or equivalent (for example: GED)
10
Business/technical school
11
Some college credit but less than 1 year
12
1 or more years of college, no degree
13
Associate degree (for example: AA, AS) (2-year)
14
Bachelor’s degree (for example: BA, AB, BS) (4-year)
15
Master’s degree (for example:
16
Professional or doctorate degree (for example: MD, DDS, JD, PhD, EdD)
17
Don’t know
18
Not applicable (no current spouse/partner)
MA, MS, MEng, MEd, MSW)
48. Which of these categories best describes the total income of all persons living in your household for the
past 12 months? (Check only one category.)
1
Less than $5,000
6
$35,000 through $49,999
2
$5,000 through $11,999
7
$50,000 through $74,999
3
$12,000 through $15,999
8
$75,000 through $99,999
4
$16,000 through $24,999
9
$100,000 and greater
5
$25,000 through $34,999
10
Don’t know
11
Prefer not to answer
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49. How many people live in your child’s main household (including the child and all parents/guardians)?
49a. Total number of people
49b. Number of children (less
than 18)
49c. Number of adults
49c(1). Of the number of adults, how many bring income into the household?
50. Is your child participating in another research study?
1
Yes
2
No
50a. If yes, what study?
As a part of the study, we will be contacting you in the future. It would be helpful to us if
you could provide us with the names, addresses, and phone numbers of two people who
could contact you even if you move.
Name
Relationship
Address:
P.O. Box
City
Street
Apt. #
State
Zip Code
Email Address
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Phone # (best)
(
(area code)
ext.
(area code)
ext.
(area code)
ext.
Phone # (other)
Phone # (other)
Name
Relationship
Address:
P.O. Box
Street
City
Apt. #
State
Zip Code
Email Address
Phone # (best)
(
(area code)
ext.
(area code)
ext.
(area code)
ext.
Phone # (other)
Phone # (other)
Thank you for completing this questionnaire.
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FOR STUDY USE ONLY
Interview Assessment:
1. How much difficulty did the Parent/Guardian have in understanding the questions?
None
Slight
Moderate
A Great Deal
Don’t know
2. Were there significant problems with the questionnaire?
Yes
No
If yes describe:
Date Completed
Completed by
Month
Mode of Administration
Day
1
In-Person
Year
2
Telephone
Reviewer Code
Date Reviewed
Month
Day
Year
Date Entered
Data Entry Code
Month
Day
Year
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| File Type | application/pdf |
| File Title | Microsoft Word - Health_Questionnaire - Parent version_ 11-01-10 revised 12-09-10 |
| Author | stmoxley |
| File Modified | 2011-05-10 |
| File Created | 2010-12-09 |