Design Your Own Retreat A few demographics to begin with! Help us find a self-care program for you! OK Question Title * 1. What is your age range? Under 18 18-24 25-34 35-44 45-54 55-64 65+ OK Question Title * 2. What gender do you associate with? Female Transgender Other (please specify) OK Question Title * 3. What is your relationship status? Single Married Divorced Widowed Domestic Partnership Separated OK Question Title * 4. What race are you? White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race OK Question Title * 5. Which of the following categories best describes your employment status? Employed, working full-time Employed, working part-time Works at home Not employed Retired Student Disabled OK Question Title * 6. What type is your diabetes? Type 1 Type 2 LADA MODY Gestational PCOS with insulin resistance Pre-Diabetes OK Question Title * 7. Do you have other medical conditions besides diabetes? Yes No OK Question Title * 8. What does caring for yourself mean? Please be as specific as possible. OK Question Title * 9. Do you ever feel? Sad Blue Fatigued Lack of Interest Lack of Motivation Depressed Overwhelmed Stressed OK Question Title * 10. Would you say you are kind to yourself on a daily basis? Yes No Sometimes Not Sure OK Question Title * 11. Are you critical of your ability to self manage your diabetes? Yes No Sometimes OK Question Title * 12. Do you feel that stress impairs / impacts your ability to care for yourself? Yes No Sometimes Not Sure OK Question Title * 13. Do you practice any creative art forms for relaxation or stress management? If so, what? Yes No If so, what? OK Question Title * 14. Who is the person or persons who are most supportive of your diabetes self-care? ( check all that apply) Partner Close family member friend who has diabetes as well friend who does not have diabetes Health Care Provider I have no other supports Other (please specify) OK Question Title * 15. Do you have diabetes influenced conditions such as..? Neuropathy Poor Circulation Diminished libido or sexual response Painful intercourse Excessive weight Lack of fitness due to extreme fatigue Other (please specify) OK Question Title * 16. Would you say any of the following are true for you? (Check all that apply) Having diabetes is a daily struggle for me Having diabetes is a major source of stress in my life I am isolated in either my work or personal life due to having diabetes I limit activities due to having diabetes OK NEXT