Diabetes Treatment Satisfaction Questionnaire

We want to hear from you

Today's Date

MM slash DD slash YYYY

Name

First Last

Date of Birth

MM slash DD slash YYYY

1. How satisfied are you with your current treatment?

0 (very satisfied)

6 (very satisfied)

2. How often have you felt that your blood sugars have been unacceptably high recently?

0 (very satisfied)

6 (very satisfied)

3. How often have you felt that your blood sugars have been unacceptably low recently?

0 (very satisfied)

6 (very satisfied)

4. How convenient have you been finding your treatment to be recently?

0 (very satisfied)

6 (very satisfied)

5. How flexible have you been finding your treatment to be recently?

0 (very satisfied)

6 (very satisfied)

6. How satisfied are you with your understanding of your diabetes?

0 (very satisfied)

6 (very satisfied)

7. Would you recommend this form of treatment to someone else with your kind of diabetes?

0 (very satisfied)

6 (very satisfied)

8. How satisfied would you be to continue with your present form of treatment?

0 (very satisfied)

6 (very satisfied)

Additional Comments:

2219 Bath Street
Santa Barbara, CA 93105

Phone: 805-682-7638
Fax: 805-682-3332
Patient Care: 805-682-4793

Tax ID # 95-1684086

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