SEARCH Low Blood Sugar Survey - Parent version

(For Parents) 2. Worry: Below is a list of concerns parents of children with diabetes sometimes have.
Read each item carefully. Circle one of the numbers that best describes HOW OFTEN YOU WORRY
ABOUT EACH ITEM.
The response categories are:

1 = Never

2 = Rarely

3 = Sometimes

4 = Often

5 = Very Often

Never

Rarely

Sometimes

Often

Very
Often

11. Child not recognizing/realizing he/she is having a
reaction.

1

2

3

4

5

12. Child not having food, fruit, or juice with him/her

1

2

3

4

5

13. Child feeling dizzy or passing out in public

1

2

3

4

5

14. Child having a reaction while asleep

1

2

3

4

5

15. Child embarrassing self or friends/family in a social
situation

1

2

3

4

5

16. Child having a reaction while alone

1

2

3

4

5

17. Child appearing “stupid” or clumsy

1

2

3

4

5

18. Child losing control

1

2

3

4

5

19. No one being around to help child during a reaction

1

2

3

4

5

20. Child making a mistake or having an accident at
school

1

2

3

4

5

21. Child getting a bad evaluation at school because of
something that happens when his/her sugar is low.

1

2

3

4

5

22. Child having seizures or convulsions

1

2

3

4

5

23. Child developing long term complications from
frequent low blood sugar

1

2

3

4

5

24. Child feeling light-headed or faint

1

2

3

4

5

25. Child having an insulin reaction

1

2

3

4

5

This is the end of the questionnaire. Thank you for answering these questions.

SEARCH 3 Cohort Study – Low Blood Sugar Survey - Parent Version – 11-01-10

Page 2 of 3

FOR STUDY USE ONLY
Date Completed

Completed By
Month

Day

Year

Date Reviewed

Reviewer Code
Month

Day

Year

Date Entered

Data Entry
Code
Month

Day

Year

SEARCH 3 Cohort Study – Low Blood Sugar Survey - Parent Version – 11-01-10

Page 3 of 3