How can we help you thrive with diabetes?

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1. 1. What city and state do you live in?

1. What city and state do you live in?   City/Town:

State:

-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

2. Gender:

MaleFemale

Gender:

3. Age:

Age:

4. Household income:

Household income:   Under $15,000 $15,000 to under $25,000 $25,000 to under $35,000 $35,000 to under $50,000 $50,000 to under $75,000 $75,000 to under $100,000 $100,000 to under $150,000 $150,000 or over I don’t wish to share this information

5. Number of children:

Number of children:   0 1 2 3 4 5 6 More than 6