SUPPLEMENTARY DIABETES QUESTIONNAIRE

This is your ID number (Used for maintaining confidentiality): $val(id)$sval(cd)/$val(qyr)/$val(spectype)

The following questions pertain to your diagnosis of diabetes.  Please respond by checking the appropriate answer and providing the requested information where indicated.  Please be as specific as possible with your answers.
All information supplied will be considered as strictly confidential and used for research purposes only. 

1. What month and year were you first diagnosed as having diabetes? _____________  month/year

2. Approximate weight at time of diagnosis: ________  pounds

3. At the time you were first diagnosed as having diabetes, was the diagnosis based on routine screening or    symptoms? _____ Screening only  ______ Symptoms

4. At the time you were first diagnosed as having diabetes, were any of the following conditions present?
                                        				NO    YES
   Ketoacidosis? ....................   			__    __
   Coma? ............................  	             		__    __
   Unintended Weight Loss?  .........                		__    __
   Unusual Hunger? ..................                     		__    __
   Unusual Thirst? ..................                        		__    __
   Unusual Frequency of Urination?...            		__    __
   Visual Changes? ..................                      		__    __

The following questions refer to the entire period that you have had diabetes (including first diagnosis and time ever since). Please include home testing.

5. How many HbA1c measurements between 5.7% and 6.4% have you ever had?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

6. How many HbA1c measurements of 6.5% or higher have you ever had?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

7. How many fasting blood glucose measurements between 126 and 139 mg/dl have you ever had?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

8. How many fasting blood glucose measurements of 140 mg/dl or higher have you ever had?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

9. How many non-fasting blood glucose measurements of 200 mg/dl or higher have you ever had? (Including    random and post meal values but not oral glucose tolerance test)

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

10. How many abnormal Oral Glucose Tolerance Tests of 200 mg/dl or higher at 2 or 3 hours have you ever had?          ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested 
11. How many urine glucose measurements of 2+ or greater have you ever had?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

12. How many times have you had ketones present (more than trace) in your urine?

   ____ None     ____ Only 1   ___ 2 or More   ____ Don't know   ___ Not tested

13. Have you ever been hospitalized for ketoacidosis?   __ No  __ Yes

    If Yes, did it ever occur within the first 2 years of diagnosis? __ No __ Yes
    (Optional) Please provide year for most recent admission for ketoacidosis:

    Year:___________   Hospital:_____________________________________________

14. Have you ever been treated with insulin injections? ___ No  ___ Yes

     If yes,
       a) When was the insulin started?   	__ At time of diagnosis
                                          			__ After diagnosis but within one year
                                          			__ More than one year after diagnosis

       b) For how long was insulin taken? ______ years

       c) What year was insulin started? _______

       d) Are you currently receiving insulin daily? __ No __ Yes

          If yes, please specify current type and dose ___________________

       e) Have you ever been able to stop your insulin completely for a period of 2 weeks or more? ___ No ___ Yes

15.  Have you ever taken oral medication for your diabetes?

          ___ No   ___  Yes, currently   ___ Yes, past only

     If yes, (either current or past only)

     a) Please give type of medication and dose ______________________________

     b) How long was oral medication taken? ______ years

     c) What year was oral medication started?  ________

16.  Additional Remarks: ___________________________________

THANK YOU!  Please return to:
Health Professionals Follow-up Study
Walter C. Willett, M.D, 
Harvard T.H. Chan School of Public Health, 
677 Huntington Avenue, Boston, MA 02115-9906       Tel: (617) 998-1067