Do you know if you are Diabetic?  Yes     No

If "Yes", Are You: Type I    Type II

How Long Have You Known That You Are Diabetic?

I'm Not Diabetic Just Found Out 1 - 5 Years 6 - 10 Years Over 10 Years

What is the primary way in which you control your diabetes?

  Insulin Injections Insulin Pump Diabetes Pills Diet and/or Exercise Complementary and Alternative Therapies

How Often Do You Check Your Blood Sugar (Glucose) Levels?
Never Occasionally Once a Week Daily More Than Once Daily

Are Other Members Of Your Family Diabetic?
Yes     No

If You Answered "Yes", Which Members Are Diabetic?

(If more than one, use Ctrl and Highlight)
Mother Father Son Daughter Grandparent Grandchild

Race and Ethnicity:
Black / African American White / Non-Hispanic Hispanic American Indian Alaska Native Asian / Pacific Islander

Age:
Under 18 18 - 25 26 - 29 30 - 39 40 - 49 50 - 59 60 or over                                    
Gender:  Male  Female

Marital Status:
Single Married Divorced Other       

Children In Household
0 1 2 3 4+

In Your Own Words, Please Tell Us What Information You Would Like To See More Of On Our Site.  Let Us Know What We Can Do To Make This Site Better For You!  We Are Here For You, And Want To Do Everything We Can To Help You Defeat Your Diabetes!