Patient info

Hello: You are invited to participate in our survey in regaurds to type 2 Diabetics in Dominica. It will take approximately 15 minutes minutes to complete the questionnaire. Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to comprehend your level of knowlege in regaurds to type 2 diabetes. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Ross Universisty School of Medicine at by email at the email address specified below. Thank you very much for your time and support.

I Agree

Contact Information

First Name :

Last Name :

Address 1 :

City :

D.O.B :

M/F :

Type 2 Diabetic (Y/N) :

Phone :

Country :

When were you Diagnosed

Do you own a glucose meter (if yes, do you know how to use it)

How Often do you test your glucose level

What was your last HgA1C and when was that

What medications are you on, right now for diabetes