S. No.: _________
Age: _____yrs Weight: ______ kg BP:_____
Sex: Male/Female/Others Height: _______ m PR:_____
Education: BMI: _______kg/m2
Occupation:
1. Are you aware of a condition called Diabetes? Yes/No
2. If Yes, how you came to know?
Newspaper
Television
Peers, Relatives
Physician
I’m a Diabetic
Others. Specify_________
3. What do you know about Diabetes?
It’s a metabolic disorder
It’s a chronic disease
It is curable
It is communicable
It is non-communicable
There is high blood sugar level
It causes damages to organs
Others. Specify ___________
4. Are you a Diabetic? Yes/No Skip to 12 if No
5. If Yes, how were you diagnosed?
Opportunistic screening
Routine check-up
Acute attack
Others
6. Are you on any medication for Diabetes? Yes/No
7. If Yes, which drug are you taking?
Insulin
Oral hypoglycaemic agents
Others. Specify________
8. Are you maintaining routine follow-up? Yes/No
9. Are you aware of the complications of diabetes? Yes/No
10. Are you having any complication? Yes/No
Questionnaire on Awareness of Diabetes Mellitus