SEARCH Health Questionnaire (Youth )

Form Approved 
OMB No. 0920‐0904 
Exp. Date 11/30/2014 

(affix label here)
Patient ID
Number

Site

Sub-site

Sequential ID

SEARCH Health Questionnaire – Young Adult Version (age 18 and older)
 The purpose of this questionnaire is to learn more about young adults who have diabetes.
 In the questionnaire, the term “doctor” refers to the doctor or other health care provider, such as a nurse.
CO-MORBIDITIES/COMPLICATIONS
1. Have you ever been tested for any genes related to diabetes?
1

 Yes

1a. Results:
1

 Don’t know

1b. When was the test done?
Month

Year

1c. Where was this test done?
2 No
3

 Don’t know

2. Has a doctor ever told you that you have high cholesterol or an abnormal amount of fat in your blood?
1

 Yes

2a. If yes, has a doctor ever prescribed medicine for high cholesterol or high fat?
1

 Yes

2

 No

3

 Don’t know

2b. Are you now taking prescribed medicine for high cholesterol or high fat?
1

 Yes

2

 No

3

 Don’t know

2c. Has a doctor ever recommended changes in your diet to lower cholesterol?
1
2

 No

3

 Don’t know

 Yes

2

 No

3

 Don’t know

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time 
for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and 
reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a 
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden 
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports 
Clearance Officer; 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0904). 
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3. Has a doctor ever told you that you have 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. Are you 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 that you had any of the following? (check yes or no for each one)
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 kidneys?
1

 Yes

2

 No

3

 Don’t know

6. Has a doctor said that diabetes has damaged the back of your 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. Have you 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. Have you already had your first period?
1

 Yes

8a. If yes, how old were you when you had your first
period?
1

2

 No

3

 Don’t know

years old

 Don’t know

9. Has a doctor ever told you that you have 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 you may have had.
10. In the last 6 months, have you been to the emergency room for any reason?

1

 Yes

2

 No

10a. How many times were you in the emergency room?

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# of times

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11. In the last 6 months, have you had one or more night’s hospital stay for any reason?

1

 Yes

2

 No

11a. How many times were you in the hospital for
one or more nights?

# of times

12. In the past 6 months, have you had any severe hypoglycemia, that is, very low blood sugar that required
you to get help?

1

2

 Yes

12a. How many times?

# of times

12b. How many times were you 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 you go to an emergency
room for hypoglycemia?

# of times

12e. How many times did you need to stay
overnight at a hospital?

# of times

 No

13. In the past 6 months, have you 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. Were you ever treated with insulin (shots/pumps) since you were 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 you 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 were you 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 you ever have any episodes of ketoacidosis (DKA) when insulin was stopped?

 Yes
2 No
3 Don’t know
1

20. How do you currently treat your diabetes? Do you 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 you are currently taking insulin, how often do you take insulin each day on average? (if you are 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 do you take insulin? (check all that apply)
1



22a. With a syringe (needle)

2



22b. With an insulin pump

3



22c. With an insulin pen
Worksheet

23. We would like to know the dose of insulin (number of units)
that you took yesterday. (If you use 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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Prescribed Medications
24. Are you taking prescribed medication(s) including insulin?
1



Yes (If Yes, document up to 10 medications below. If you are taking insulin, be certain to include all types



No (if No, skip to question 25)

or preparations.)
2

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.
25. In the past 12 months have you met with a diabetes
nurse or diabetes educator?

1

 Yes

2

 No

3

 Don’t know

26. In the past 12 months have you met with a dietician or nutritionist, or talked to someone in detail about
your diet?
1

2

 Yes

26a. When you were staying one or
more nights in the hospital

1

 Yes

2

 No

3

 Don’t know

26b. As an outpatient

1

 Yes

2

 No

3

 Don’t know

 No

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27. In the past 12 months, which of the following types of diabetes information have you received from your
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

28. How would you rate your diabetes control: Would you say:

 Excellent
2 Good
3 Fair
4 Needs much work
1

Home Diabetes Care

 Here are some questions about your diabetes care outside of the doctor’s office.
29. Do you live or stay in more than one home on a regular basis? For example, if your parents are separated,
this would include spending the weekend with your other parent. It would also include other relatives you
might live or stay with on a regular basis (at least once per month).
1

2

 Yes



29a. If yes, do you live in:
1

 2 households

2

 3 or more households

3

 Don’t know

No, live in one household

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30. How much of your own diabetes care do you do for yourself? Would you say: (check one response)

 None
2 Less than 25%
3 25-75%
4 More than 75%
5 All (skip to question 32)
1

31. Who helps you with your diabetes care?
31a. Parent/step parent/guardian

1

 Yes

2

 No

31b. Grandparent

1

 Yes

2

 No

31c. Brother/sister

1

 Yes

2

 No

31d. Another person

1

 Yes

2

 No

32. Do you test your blood sugar or glucose at home or any place other than the doctor’s office?
1

 Yes

 No (if
no, go to
question 33)

2

32a. How often is your blood sugar checked with a glucose meter (glucometer)? (check one)

 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
1

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32b. Do you use a continuous glucose monitor (CGM) to measure your glucose?

 Yes
2 No (if no go to 32c)
1

32b(1). If yes, how do you use the CGM?
1

 I have used it through my doctor’s office
How often have you
used it?

2

 1 time
2 2 or more times
3 Don’t know/not sure
1

 I have a CGM for use at home
How often do you use it?
1 Rarely (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
2

32c. What do you usually do when the blood sugar test results are running too high or too low?
32c(1). Make changes to the diabetes treatment (insulin
dose or other medications, diet or exercise

1

 Yes

2

 No

32c(2). Call your diabetes doctor

1

 Yes

2

 No

32c(3). Talk to your 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 you see.
33. Who do you usually see for your 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

34. Who do you usually see for your 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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 Below are some questions about how often you see various medical providers.
35. Who provides medical care for you? (For each provider checked, indicate the number of visits you had with

this provider in the past 6 months.)
35a.

1

 Yes

2

 No

Pediatric endocrinologist/
diabetologist (diabetes specialist)

# of visits in the
last 6 months

35b.

1

 Yes

2

 No

Pediatrician

# of visits in the
last 6 months

35c.

1

 Yes

2

 No

Family practice doctor

# of visits in the
last 6 months

35d.

1

 Yes

2

 No

General practice doctor

# of visits in the
last 6 months

35e.

1

 Yes

2

 No

Adult endocrinologist/
diabetologist (diabetes specialist)

# of visits in the
last 6 months

35f.

1

 Yes

2

 No

Internist

# of visits in the
last 6 months

35g.

1

 Yes

2

 No

Nurse practitioner/physician’s
assistant

# of visits in the
last 6 months

35h.

1

 Yes

2

 No

Nurse diabetes educator

# of visits in the
last 6 months

35i.

1

 Yes

2

 No

Traditional medicine man, healer,
or curandero/curandera

# of visits in the
last 6 months

35j.

1

 Yes

2

 No

Dietician

# of visits in the
last 6 months

35k.

1

 Yes

2

 No

Eye doctor (optometrist,
ophthalmologist)

35l.

1

 Yes

2

 No

Psychiatrist, psychologist, or
mental health counselor

35m.

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
36. What kind of health insurance or health care plan do you have?
36a. Medicaid/Medicare/State-funded/ other Federally-funded

1

 Yes

2

 No

36b. Private insurance, through employer

1

 Yes

2

 No

36c. Private insurance, purchased on your own

1

 Yes

2

 No

36d. Military

1

 Yes

2

 No

36e. School-based insurance

1

 Yes

2

 No

36f. Tribe/Indian Health Service

1

 Yes

2

 No

36g. Any other or type unknown

1

 Yes

2

 No

36h. None (if none, go to question 38)

1

 Yes

2

 No

37. Does your health insurance or health care plan pay for any of your… (check yes, no or don’t know for each one)
37a. Diabetes medicine/insulin

1

 Yes

2

 No

3

 Don’t know

37b. Syringes/pens/needles

1

 Yes

2

 No

3

 Don’t know

37c. Insulin pump and supplies

1

 Yes

2

 No

3

 Don’t know

37d. Home glucose monitor

1

 Yes

2

 No

3

 Don’t know

37e. Monitor strips and related supplies

1

 Yes

2

 No

3

 Don’t know

37f. Diabetes education

1

 Yes

2

 No

3

 Don’t know

37g.

 Not applicable

38. 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 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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39. How satisfied are you with your current insurance coverage? Would you say:
1

 Very satisfied

2

 Satisfied

3

 Somewhat satisfied

4

 Not satisfied

40. Has your main health insurance plan changed in the last 6 months?
1

 Yes (if yes, go to question 40a)

2

 No (if no, go to question 41)

 Don’t know
4 Don’t want to answer
3

40a. What were the reasons your 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)

41. Has your main diabetes provider changed in the last six months?
1

 Yes (if yes, go to question 41a)

2

 No (if no, go to question 42)

3

 Don’t know

4

 Don’t want to answer

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What were the reasons you had a change in diabetes provider? (check all that apply)

41a.

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 your parents’ education.
42. What is the highest degree or level of school your mother/guardian has 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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43. What is the highest degree or level of school your father/guardian 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

MA, MS, MEng, MEd, MSW)

44. Which of these categories best describes the total income of all persons living in your household, including
yourself 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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45. How many people are currently living in your household, including yourself?
45a. Total number of people
45b. Number of children (less
than 18)
45c. Number of adults
45c(1). Of the number of adults, how many bring income into the household?
46. Are you participating in another research study?
1

 Yes

2

 No

46a. 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
Date Completed

Completed by
Month

Day

Year

Reviewer Code

Date Reviewed
Month

Day

Year

Date Entered

Data Entry Code
Month

Day

Year

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