Please take a few minutes to complete this confidential 13-item questionnaire.


Is this your first time taking this questionnaire? yes   no  


Age: under 18   18-30   31-40   41-60   over 60
Gender: male   female

Listed below are reasons why you might or might not want to use an insulin pump. Please consider how strongly you agree or disagree with each of these.

 
strongly disagree
moderately disagree
slightly disagree
slightly agree
moderately agree
strongly agree
1. I don't like the idea of being hooked up to something 24 hours/day.
2. If I used a pump, I would probably have more stable blood sugars, with fewer ups and downs every day.
3. I am concerned that the pump might cause serious hypoglycemic episodes
4. I don't like the idea of a needle sticking in me all the time.

Click the MORE QUESTIONS button to continue completing the questionnaire.

 
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