Problem areas in diabetes questionnaire

First Name *

Last Name *

DOB: *

Which of the following diabetes issues are currently a problem for you? *

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Not having clear and concrete goals for your diabetes care

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling discouraged with your diabetes treatment plan

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling scared when you think about living with diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Uncomfortable social situations related to your diabetes care (eg people telling you what to eat)

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feelings of deprivation regarding food and meals

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling depressed when you think about living with diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Not knowing if your mood or feelings are related to your diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling overwhelmed by your diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Worrying about low blood sugar reactions

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling angry when you think about living with diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling constantly concerned about food and eating

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Worrying about the future and the possibility of serious diabetes complications

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feelings of guilt or anxiety when you get off track with your diabetes management

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Not ‘accepting’ your diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling unsatisfied with your diabetes physician

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling that diabetes is taking up too much of your mental and physical energy every day

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling alone with your diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling that your friends and family are not supportive of your diabetes management efforts

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Coping with complications of diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Feeling ‘burned out’ by the constant effort needed to manage diabetes

Not a problemMinor problemModerate problemSomewhat serious problemSerious problem

Assessment *

An assessment score of 40 or more indicates severe diabetes-related distress and warrants further exploration and discussion with the patient.

Source: Joslin Diabetes Center and RACGP.

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