Diabetes Questionnaire

1. Age?

• under 18
• 18-24
• 25-34
• 35-54
• 55+

2. The Type of Diabetes you have?

• Type 1
• Type 2

3. Which Insulin Delivery device do you use?

• Syringe
• Insulin Pen
• Insulin Pump
• None / Other

4. Do you Participate in regular exercise?

• Yes
• No

5. Do you Travel often?

• Yes
• No

6. In relation to the last two questions, do you have problems keeping your equipment safe? ie ( Insulin, syringes, pens, cartridges, vials and glucose meters)

• Yes
• No

8. Do you prefer your insulin case to be discreet or stand out??

• Discreet
• Stand out

10. I hereby give consent for this information to be used in a research project. *This question is required.

• Yes
• No