Diabetes Care Survey

Please take a moment to complete this survey which will be used by local health agencies to help improve diabetic education services in our community. Thank you!

-Grant Regional Health Center, Grant County Health Department, Aging & Disability Resource Center and the Lancaster Lions Club, and funded by the Office of Wisconsin Rural Health

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* 1. Are you:

Male

Female

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* 2. What is your age:

0-20 yrs

21-30 yrs

31-40 yrs

41-50 yrs

51-60 yrs

61-70 yrs

71+ yrs

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* 3. Are you diabetic?

Yes

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* 4. Do you live with or care for someone with diabetes?

Yes

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* 5. Do you know if your local hospital offers Diabetic Education?

Yes

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* 6. Where would you seek diabetes information for yourself or a loved one if needed? (check all that apply.)

Primary Care Provider (MD, PA, NP)

Internet/Facebook

Friend/Relative

American Diabetes Association

County Health Department/WIC Clinics

Aging & Disability Resource Center

Local Hospital

Magazine/Newsletters/Print Material

Support Groups

Other (please specify)

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* 7. What diabetic resources should be added in your community to improve awareness of diabetes and it's long-term problems?

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* 8. What, if anything, limits your access to healthcare?

Insurance/Lack of Insurance

High Co-Payments/High Deductibles

Transportation

Lack of Specialists nearby

Desire not to seek healthcare

Other (please specify)