Section A
1. What gender do you identify as?
2. What is your age (years)?
3. Where do you live (country)?
4. What is your height (cm)?
Feet
ft
Inches
in
cm
5. What is yout weight (kg)?
pound
lb
Kg
6. What is the highest degree or level of education you have completed?
7. What is your marital status?
8. Including yourself, how many people live in your household?
9. With how many people do you feel comfortable talking about your feelings and emotions?
10. How long ago were you diagnosed with diabetes mellitus type 1?
11. What was your latest HbA1c result (DCCT-%)?
eAG
%
12. When was your latest HbA1c blood test?
13. How do you monitor your glucose blood level?
14. How do you deliver your insulin therapy?
15. Do you think the measured blood sugar values are affected by your emotions?
16. Do you think your ability to balance blood sugar values is affected by your personality traits?
17. How would you describe your night sleep during the past month?
17.2. What affects your night sleep quality
18. Do you suffer from chronic illness other than type 1 diabetes mellitus?
18.2. If you do suffer from a chronic illness does it impact your sleep?
19.Are you diagnosed with a mental condition?
Section B
I see myself as someone who is reserved
I see myself as someone who is generally trusting
I see myself as someone who does a thorough job
I see myself as someone who is relaxed, handles stress well
I see myself as someone who has an active imagination
I see myself as someone who is outgoing, sociable
I see myself as someone who tends to find faults with others
I see myself as someone who tends to be lazy
I see myself as someone who gets nervous easily
I see myself as someone who has few artistic interests
I get angry sometimes
Everything tastes the same
the form was not submitted, please be sure you have answered all the questions
form submitted successfully