Survey on Living with Chronic Diseases in Canada (SLCDC)- Diabetes Component

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For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.

Table of Contents

Survey Introduction (XINT)

Survey Introduction (XINT) - Question identifier:XINT_R01

This survey is conducted under the authority of the Statistics Act in collaboration with the Public Health Agency of Canada. You may remember recently completing the Canadian Community Health Survey - this is a follow-up to that survey. The purpose of this survey is to collect information on Canadians with chronic health conditions. Data from the survey will be used by health professionals and public health programs, with the aim of improving health outcomes for Canadians with chronic conditions.

Survey Introduction (XINT) - Question identifier:XINT_R02

Your answers will be kept strictly confidential and used only for statistical purposes. While participation is voluntary, your assistance is essential if the results are to be accurate.

(Registration #: STC/HLT-082-75437)

General health (XGEN)

General health (XGEN) - Question identifier:XGEN_R01

I would like to start with some general background questions.

General health (XGEN) - Question identifier:XGEN_Q01

In general, would you say your health is:

1. ... excellent?
2. ... very good?
3. ... good?
4. ... fair?
5. ... poor?
DK, RF

General health (XGEN) - Question identifier:XGEN_Q02

Compared to one year ago, how would you say your health is now? Is it:

1. ... much better now than 1 year ago?
2. ... somewhat better now (than 1 year ago)?
3. ... about the same as 1 year ago?
4. ... somewhat worse now (than 1 year ago)?
5. ... much worse now (than 1 year ago)?
DK, RF

General health (XGEN) - Question identifier:XGEN_Q03

How satisfied are you with your life in general?

1. Very satisfied
2. Satisfied
3. Neither satisfied nor dissatisfied
4. Dissatisfied
5. Very dissatisfied
DK, RF

General health (XGEN) - Question identifier:XGEN_Q04

In general, would you say your mental health is:

1. ... excellent?
2. ... very good?
3. ... good?
4. ... fair?
5. ... poor?
DK, RF

General health (XGEN) - Question identifier:XGEN_Q05

Thinking about the amount of stress in your life, would you say that most days are:

1. ... not at all stressful?
2. ... not very stressful?
3. ... a bit stressful?
4. ... quite a bit stressful?
5. ... extremely stressful?
DK, RF

Confirmation of diabetes diagnosis (XCND)

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_R01

Now I would like to ask some questions about diabetes.

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q01

To begin, do you have diabetes that has been diagnosed by a health professional?

1. Yes
2. No

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q02

Have you ever been diagnosed with diabetes?

1. Yes
2. No

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q03

During the CCHS interview, it was reported that you have diabetes but this time it was reported that you do not. Is this because you control your diabetes through medication or changes to your lifestyle, not being officially diagnosed, or to something else?

1. Error in CCHS - never had diabetes
2. Diabetes was never diagnosed by a health professional
3. Takes medication that controls diabetes
4. Made changes to lifestyle that control diabetes
5. Other
DK, RF

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_R04

You have said that you don't feel that you have diabetes anymore because you are able to control it through medication or changes in your lifestyle. Even though your diabetes is controlled, we are still interested in hearing about your experiences.

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q04

Were you pregnant when you were first diagnosed with diabetes?

1. Yes
2. No
DK, RF

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q05

Other than during pregnancy, has a health professional ever told you that you have diabetes?

1. Yes
2. No
DK, RF

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q06

Do you know the kind of diabetes you have?

1. Yes
2. No
DK, RF

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q07

What kind of diabetes do you have?

1. Type 1 (also known as juvenile diabetes)
2. Type 2 (also known as adult onset diabetes)
3. Other
DK, RF

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_Q08

How old were you when you were first diagnosed with diabetes ^DT_DIAGE?

Minimum: 0 Maximum: 130

Confirmation of diabetes diagnosis (XCND) - Question identifier:XCND_R09

You have said that you do not have diabetes (or have pregnancy-induced diabetes only). Since this survey applies only to people with diabetes, (excluding pregnancy-induced diabetes,) you are not eligible to participate in today's survey. Thank you for your time.

Health care utilization (XHUD)

Health care utilization (XHUD) - Question identifier:XHUD_Q01

Which of the following health professionals or practitioners do you consider most responsible for treating your diabetes?

1. Family doctor or general practitioner
2. Other medical doctor or specialist
3. Diabetes educator
4. Nurse or nurse practitioner
5. Pharmacist
6. Other health professional
7. No health professional responsible for treating diabetes
DK
RF

Health care utilization (XHUD) - Question identifier:XHUD_R02

Now I'd like to ask about your contacts with various health professionals during the past 12 months.

Health care utilization (XHUD) - Question identifier:XHUD_Q02

In the past 12 months, have you seen, or talked to any of the following health professionals:

... a diabetes specialist, endocrinologist, or internist?

1. Yes
2. No
DK, RF

Health care utilization (XHUD) - Question identifier:XHUD_Q03

In the past 12 months, have you seen, or talked to:

... a kidney specialist or nephrologist?

1. Yes
2. No
DK, RF

Health care utilization (XHUD) - Question identifier:XHUD_Q04

(In the past 12 months, have you seen, or talked to:)

... a podiatrist or foot specialist?

1. Yes
2. No
DK, RF

Health care utilization (XHUD) - Question identifier:XHUD_Q05

(In the past 12 months, have you seen, or talked to:)

... a dietitian or nutritionist?

1. Yes
2. No
DK, RF

Health care utilization (XHUD) - Question identifier:XHUD_Q06

(In the past 12 months, have you seen, or talked to:)

... a complementary or alternative health care practitioner such as a naturopath or herbalist about your diabetes?

1. Yes
2. No
DK, RF

Health care utilization (XHUD) - Question identifier:XHUD_Q07

In the past 12 months, did you ever experience any difficulties getting the routine or ongoing care you needed for your diabetes?

1. Yes
2. No
DK, RF

Clinical Monitoring (XCOD)

Clinical Monitoring (XCOD) - Question identifier:XCOD_R01

Now some questions about tests you may have been given by a health professional to help monitor your diabetes.

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q01

Has a health professional ever given you an "A one C" test, also known as a glycosylated hemoglobin test? A test for "A one C" is a measure of your average blood sugar level over the past three months.

1. Yes
2. No
DK
RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q02

How many times in the past 12 months have you had your "A one C" (glycosylated hemoglobin) measured by a health professional?

Minimum: 0 Maximum: 365

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q03

The last time your "A one C" (glycosylated hemoglobin) was measured by a health professional, were you told that your blood sugar was:

1. ... normal (fine, ok, well-controlled)?
2. ... borderline?
3. ... high?
4. ... low?
5. Health professional did not say
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q04

How often does your health professional check your blood pressure at your diabetes-related appointments?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q05

The last time your blood pressure was measured by a health professional, were you told that your blood pressure was:

1. ... normal (fine, ok, well-controlled)?
2. ... borderline?
3. ... high?
4. ... low?
5. Health professional did not say
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q06

Have you ever had your blood cholesterol checked by a health professional?

1. Yes
2. No
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q07

When was the last time you had your blood cholesterol measured by a health professional? Was it:

1. ... less than 6 months ago?
2. ... 6 months to less than 1 year ago?
3. ... 1 year to less than 2 years ago?
4. ... 2 years to less than 3 years ago?
5. ... 3 or more years ago?
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q08

The last time your blood cholesterol was measured by a health professional, were you told that your blood cholesterol was:

1. ... normal (fine, ok, well-controlled)?
2. ... borderline?
3. ... high?
4. ... low?
5. Health professional did not say
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q09

In the past 12 months, has a health professional checked your feet for any sores or irritations?

1. Yes
2. No
3. No feet
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q10

How many times? (In the past 12 months, has a health professional checked your feet for any sores or irritations?)

Minimum: 0 Maximum: 99

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q11

Have you ever had an eye exam where the pupils of your eyes were dilated? (This procedure is done using eye drops and would have made you temporarily sensitive to light.)

1. Yes
2. No
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q12

When was the last time (you had your pupils dilated)? Was it:

1. ... less than 1 year ago?
2. ... 1 year to less than 2 years ago?
3. ... 2 or more years ago?
DK, RF

Clinical Monitoring (XCOD) - Question identifier:XCOD_Q13

In the past 12 months, has a health professional measured your weight on a scale?

1. Yes
2. No
DK, RF

Medication use (XMED)

Medication use (XMED) - Question identifier:XMED_R01

The next few questions are about medications that have been prescribed by a doctor or other health professional.

Medication use (XMED) - Question identifier:XMED_Q01

Currently, are you taking any prescription medications, including medications taken for diabetes? Please include any pills, needles, liquids or inhalers that have been prescribed by a health professional for any health condition.

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q02

Currently, how many different types of prescription medications are you taking? (Please include any pills, needles, liquids or inhalers that have been prescribed by a health professional for any health condition.)

1. One
2. Two
3. Three or four
4. Five to nine
5. Ten or more
DK, RF

Medication use (XMED) - Question identifier:XMED_Q03

Do you currently take pills that were prescribed by a doctor or health professional to control your blood sugar?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q04

Currently, how many different types of pills are you taking to control your blood sugar?

1. One
2. Two
3. Three
4. Four or more
DK, RF

Medication use (XMED) - Question identifier:XMED_Q05

Have you ever taken insulin injections for your diabetes?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q06

Thinking back to when you were first diagnosed with ^DT_DIABETESE, how long was it before you started insulin injections?

1. Less than 1 year
2. 1 year to less than 2 years
3. 2 or more years
4. Never
DK, RF

Medication use (XMED) - Question identifier:XMED_Q07

Do you currently take insulin injections for your diabetes?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q08

Currently, do you take aspirin or other ASA (acetylsalicylic acid) medication every day or every second day?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q09

Do you currently take prescription medications to control high blood pressure?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q10

Currently, how many different types of prescription medication are you taking to control high blood pressure?

1. One
2. Two
3. Three
4. Four or more
DK, RF

Medication use (XMED) - Question identifier:XMED_Q11

Currently, do you take prescription medications to control your blood cholesterol levels?

1. Yes
2. No
DK, RF

Medication use (XMED) - Question identifier:XMED_Q12

Thinking of all the prescription medications you take for your diabetes and its complications, in the past 12 months, on average, would you say you:

1. ... took the medication as often as prescribed?
2. ... took the medication more often than prescribed?
3. ... took the medication less often than prescribed?
4. ... occasionally missed a dose?
5. ... do not take the medication at all.
DK, RF

Medication use (XMED) - Question identifier:XMED_Q13

Currently, do you take any herbal or naturopathic remedies to treat your diabetes?

1. Yes
2. No
DK, RF

Insurance coverage (XICD)

Insurance coverage (XICD) - Question identifier:XICD_R01

Now, turning to your insurance coverage. Please include any private, government or employer-paid plans.

Insurance coverage (XICD) - Question identifier:XICD_Q01

Do you have insurance that covers all or part of the cost of your prescription medications?

1. Yes
2. No
DK
RF

Insurance coverage (XICD) - Question identifier:XICD_Q02

Do you have insurance that covers all or part of:

... the cost of your glucose monitoring equipment and supplies (for example, needles and test strips)?

1. Yes
2. No
DK, RF

Insurance coverage (XICD) - Question identifier:XICD_Q03

(Do you have insurance that covers all or part of:)

... your dental expenses?

1. Yes
2. No
DK, RF

Insurance coverage (XICD) - Question identifier:XICD_Q04

(Do you have insurance that covers all or part of:)

... the cost of your eye care appointments?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD)

Clinical recommendations (XCLD) - Question identifier:XCLD_R01

The next questions are about things that a doctor or other health professional may have discussed with you to help control your diabetes. You may feel that some of these questions do not apply to you, but it is important that we ask the same questions of everyone.

Clinical recommendations (XCLD) - Question identifier:XCLD_Q01

In the past 12 months, has a doctor or other health professional discussed:

... taking prescription medication to help you control your diabetes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q02

In the past 12 months, has a doctor or other health professional discussed:

... changing the type or amount of food you eat to help control your diabetes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q03

(In the past 12 months, has a doctor or other health professional discussed:)

... participating in physical activity or exercise to help you control your diabetes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q04

(In the past 12 months, has a doctor or other health professional discussed:)

... controlling or losing weight to help you control your diabetes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q05

(In the past 12 months, has a doctor or other health professional discussed:)

... stress-management with you?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q06

At any time since you were first diagnosed with diabetes, have you smoked cigarettes, cigars or pipes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q07

In the past 12 months, have you smoked cigarettes, cigars or pipes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q08

In the past 12 months, has a doctor or other health professional discussed:

... quitting or cutting down smoking?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q09

At any time since you were first diagnosed with diabetes, did you regularly drink more than ^DT_DRINK drinks a week? When we use the word "drink" it means: one bottle or can of beer or a glass of draft, one glass of wine or a wine cooler, or one drink or cocktail with 1 and a 1/2 ounces of liquor.

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q10

In the past 12 months, did you regularly drink more than ^DT_DRINK drinks a week?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q11

In the past 12 months, has a doctor or other health professional discussed:

... limiting alcohol consumption to help you control your diabetes?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q12

Has a doctor or other health professional ever discussed the complications of diabetes with you?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q13

Has a doctor or other health professional ever recommended monitoring your blood sugar at home?

1. Yes
2. No
DK, RF

Clinical recommendations (XCLD) - Question identifier:XCLD_Q14

Has a doctor or other health professional ever recommended monitoring your blood pressure at home using a home blood pressure monitor?

1. Yes
2. No
DK, RF

Self-management (XSMD)

Self-management (XSMD) - Question identifier:XSMD_R01

The next questions are about things that people might do as a result of being diagnosed with diabetes.

Self-management (XSMD) - Question identifier:XSMD_Q01A

As a result of being diagnosed with diabetes, did you ever change the type or amount of food you eat to help control your diabetes?

1. Yes
2. No
DK
RF

Self-management (XSMD) - Question identifier:XSMD_Q01B

Are you still doing this:

1. ... all the time?
2. ... most of the time?
3. ... some of the time?
4. ... none of the time?
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q02

What are the reasons why ^DT_FOOD change the type or amount of food you eat to help control your diabetes?

1. Lack of will power / self-discipline
2. Does not like to eat healthier foods
3. Time constraints (too busy, family responsibilities, work schedule, etc.)
4. Already changed diet for other reasons
5. Too costly / financial constraints
6. Taking medication to control diabetes
7. Does not think that changing diet is important/recommended
8. Other
9. No reason for not changing diet
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q03A

As a result of being diagnosed with diabetes, did you ever change the amount of exercise you do or participate in physical activities to help control your diabetes?

1. Yes
2. No
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q03B

Are you still doing this:

1. ... all the time?
2. ... most of the time?
3. ... some of the time?
4. ... none of the time?
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q04

What are the reasons why ^DT_ACTIVITY exercise or participate in physical activity to help control your diabetes?

1. Lack of will power / self-discipline
2. Does not like to exercise
3. Time constraints (too busy, family responsibilities, work schedule, etc.)
4. Already doing physical activities or exercise for other reasons
5. Physical condition or a health problem
6. Too costly / financial constraints
7. Not available in area
8. Taking medication to control diabetes
9. Does not think that exercise is important/recommended
10. Other
11. No reason for not exercising
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q05B

Have you been able to maintain or achieve your goal weight?

1. Yes
2. No
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q06

What are the reasons why you ^DT_WEIGHT to lose weight to help control your diabetes?

1. Does not need to lose weight - already a healthy weight
2. Still trying to lose weight
3. Lack of will power / self-discipline
4. Does not want to lose weight
5. Tried to lose weight - didn't work
6. Time constraints (too busy, family responsibilities, work schedule, etc.)
7. Already losing weight for other reasons
8. Disability / health problem other than diabetes makes it hard to lose weight
9. Too costly / financial constraints
10. Taking medication to control diabetes
11. Does not think that weight loss is important/recommended
12. Other
13. No reason for not trying to lose weight
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q07A

As a result of being diagnosed with diabetes, did you ever quit smoking?

1. Yes
2. No
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q07B

Are you continuing to maintain this change?

1. Yes
2. No
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q09A

As a result of being diagnosed with diabetes, did you stop drinking or limit your alcohol consumption to help control your diabetes?

1. Yes
2. No
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q09B

Are you continuing to maintain this change in your alcohol consumption:

1. ... all the time?
2. ... most of the time?
3. ... some of the time?
4. ... none of the time?
DK, RF

Self-management (XSMD) - Question identifier:XSMD_Q10

In the past 12 months, have you used any of the following services or programs to help manage your diabetes?

1. Diabetes Centre
2. Fitness facilities or programs
3. Educational programs
4. Stress management programs
5. Smoking cessation programs
6. Support groups
7. Self-help groups
8. Walking programs (for example, mall walking)
9. Did not use any services or programs to help manage diabetes
DK, RF

Self-monitoring (XMOD)

Self-monitoring (XMOD) - Question identifier:XMOD_R01

The next few questions are about diabetes monitoring you may do yourself outside of a health professional's office or medical clinic.

Self-monitoring (XMOD) - Question identifier:XMOD_Q01

Do you or a family member or friend check your blood sugar?

1. Yes
2. No
DK
RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q02

How often do you or a family member or friend usually check your blood sugar?

1. Per day
2. Per week
3. Per month
4. Per year
5. Never
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_N02B

Enter number of times per day.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N02C

Enter number of times per week.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N02D

Enter number of times per month.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N02E

Enter number of times per year.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_Q03

How often do you bring a record of your home blood sugar test results to your appointments with a health professional?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q04

In general, do you consider your blood sugar to be:

1. ... well-controlled (normal, fine, ok)?
2. ... borderline?
3. ... high?
4. ... low?
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q05

Do you measure your blood pressure with a home blood pressure monitoring device?

1. Yes
2. No
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q06

How often do you or a family member or friend usually check your blood pressure with a home blood pressure monitoring device?

1. Per day
2. Per week
3. Per month
4. Per year
5. Never
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_N06B

Enter number of times per day.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N06C

Enter number of times per week.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N06E

Enter number of times per year.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_Q07

In general, do you consider your blood pressure to be:

1. ... well-controlled (normal, fine, ok)?
2. ... borderline?
3. ... high?
4. ... low?
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q08

Do you or a family member or friend check your feet for any sores or irritations?

1. Yes
2. No
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_Q09

How often do you or a family member or friend usually check your feet for any sores or irritations?

1. Per day
2. Per week
3. Per month
4. Per year
5. Never
DK, RF

Self-monitoring (XMOD) - Question identifier:XMOD_N10B

Enter number of times per day.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N10C

Enter number of times per week.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N10D

Enter number of times per month.

Minimum: 1 Maximum: 99

Self-monitoring (XMOD) - Question identifier:XMOD_N10E

Enter number of times per year.

Minimum: 1 Maximum: 99

Diabetes complications (XDCD)

Diabetes complications (XDCD) - Question identifier:XDCD_R01

The next few questions are about symptoms and complications you may have experienced as a result of having diabetes.

Diabetes complications (XDCD) - Question identifier:XDCD_Q02

In the past 12 months, did you ever have to visit an emergency room because of low blood sugar (hypoglycemia)?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q03

Have you ever had any of the following conditions diagnosed by a health professional:

... diabetic eye disease or diabetic retinopathy?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q04

Have you ever had any of the following conditions diagnosed by a health professional:

... partial or complete blindness?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q05

(Have you ever had any of the following conditions diagnosed by a health professional:)

... cataracts?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q06

(Have you ever had any of the following conditions diagnosed by a health professional:)

... glaucoma?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q07

(Have you ever had any of the following conditions diagnosed by a health professional:)

... protein in your urine?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q08

Have you ever had any of the following conditions diagnosed by a health professional:

... kidney failure?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q10

(Have you ever had any of the following conditions diagnosed by a health professional:)

... heart disease (for example, angina, heart attack)?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q11

(Have you ever had any of the following conditions diagnosed by a health professional:)

... high blood pressure?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q12

Have you ever had any of the following conditions diagnosed by a health professional:

... stroke or mini-stroke?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q13

(Have you ever had any of the following conditions diagnosed by a health professional:)

... erectile dysfunction?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q14

(Have you ever had any of the following conditions diagnosed by a health professional:)

... poor circulation in the feet or legs?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q15

(Have you ever had any of the following conditions diagnosed by a health professional:)

... foot or leg ulcers or infection?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q16

Have you ever had any of the following conditions diagnosed by a health professional:

... gangrene and/or amputation?

1. Yes
2. No
DK, RF

Diabetes complications (XDCD) - Question identifier:XDCD_Q17

(Have you ever had any of the following conditions diagnosed by a health professional:)

... problems with your gums?

1. Yes
2. No
DK, RF

Restriction of activities (XRAD)

Restriction of activities (XRAD) - Question identifier:XRAD_R01

The next few questions deal with any limitations in your usual activities caused by your diabetes.

Restriction of activities (XRAD) - Question identifier:XRAD_Q01

In the past 12 months, how much did your diabetes limit you:

... in social activities with family or friends?

1. A lot
2. A little
3. Not at all
DK
RF

Restriction of activities (XRAD) - Question identifier:XRAD_Q02

In the past 12 months, how much did your diabetes limit you:

... in activities such as recreation, leisure or hobbies?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAD) - Question identifier:XRAD_Q03

(In the past 12 months, how much did your diabetes limit you:)

... in doing household chores?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAD) - Question identifier:XRAD_Q04

(In the past 12 months, how much did your diabetes limit you:)

... in running errands or shopping?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAD) - Question identifier:XRAD_Q05

Have you had to stop driving because of your diabetes?

1. Yes
2. No
3. NA - has never driven a car
DK, RF

Restriction of activities (XRAD) - Question identifier:XRAD_Q06

Overall, how much does your diabetes affect your life?

1. Not at all
2. A little bit
3. Moderately
4. Quite a bit
5. Extremely
DK, RF

Restriction of work-related activities (XRWD)

Restriction of work-related activities (XRWD) - Question identifier:XRWD_R01

The next questions concern your work activities.

Restriction of work-related activities (XRWD) - Question identifier:XRWD_Q01

Are you currently working for pay at a job or business?

1. Yes
2. No
DK
RF

Restriction of work-related activities (XRWD) - Question identifier:XRWD_Q02

Have you ever worked for pay at a job or business?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWD) - Question identifier:XRWD_Q03

Did you have diabetes while you were working?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWD) - Question identifier:XRWD_Q04

Because of your diabetes, did you ever:

... change the number of hours or the type of work you ^DT_DODID, the way in which you ^DT_CARRY out your tasks at work or stop working permanently?

1. Yes
2. No
DK, RF

Support and well-being (XSWD)

Support and well-being (XSWD) - Question identifier:XSWD_R01

Next are some questions about the support that is available to you if you need it.

Support and well-being (XSWD) - Question identifier:XSWD_Q01

How often are the following kinds of support available to you if you need it:

... someone to take you to the doctor?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
DK, RF

Support and well-being (XSWD) - Question identifier:XSWD_Q02

(How often are the following kinds of support available to you if you need it:)

... someone to confide in or talk to about your diabetes management or diabetes-related problems?

1. Always
2. Often
3. Sometimes
4. Rarely
5. Never
DK, RF

Support and well-being (XSWD) - Question identifier:XSWD_Q03

(How often are the following kinds of support available to you if you need it:)

... someone to prepare your meals if you were unable to do it yourself because of your diabetes?

Patient Activation (XPAD)

Patient Activation (XPAD) - Question identifier:XPAD_R01

I'm going to read you a series of statements related to how involved you are in thinking about or making decisions about your diabetes and diabetes care. Please say whether you strongly agree, agree, disagree, or strongly disagree with each of the following statements.

Patient Activation (XPAD) - Question identifier:XPAD_Q01

I know what each of my prescribed medications do.

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
DK, RF

Patient Activation (XPAD) - Question identifier:XPAD_Q02

I am confident that I can follow through on medical treatments I need to do at home.

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
DK, RF

Patient Activation (XPAD) - Question identifier:XPAD_Q03

I understand the nature and causes of my diabetes.

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
DK, RF

Patient Activation (XPAD) - Question identifier:XPAD_Q04

I know how to prevent further problems with my diabetes.

1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
DK, RF

Administration (XADM)

Administration (XADM) - Question identifier:XADM_R01A

The next few questions are about linking the information from today's interview to your information from the Canadian Community Health Survey and sharing this information with other government organizations.

We will be asking your parent or guardian the same questions after you have answered them.

Administration (XADM) - Question identifier:XADM_R01B

In 2010, you responded to the Canadian Community Health Survey. At that time, you gave permission for ^DT_QUEBECHNE to link information from that survey to your health services information. You also gave us your provincial health number to assist in linking this information.

Administration (XADM) - Question identifier:XADM_R01C

In order to reduce the number of questions on today's survey, Statistics Canada would like to link information from this interview with your information from the 2010 Canadian Community Health Survey.

Administration (XADM) - Question identifier:XADM_Q01

The linked information will be kept strictly confidential and used only for statistical purposes.

Do we have your permission?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R02

Statistics Canada would like your permission to share the linked survey data, that is your information from today's interview and your information from the Canadian Community Health Survey, with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_R03

Although you do not agree to link the information collected in today's interview to the 2010 Canadian Community Health Survey, we would like your permission to share only the information collected today with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q03

Your personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

Administration (XADM) - Question identifier:XADM_R04

Although you do not agree to share the linked survey information, we would like your permission to share only the information collected in today's interview with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Although you do not agree to share the linked survey information, we would like your permission to share only the information collected in today's interview with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Although you do not agree to share the linked survey information, we would like your permission to share only the information collected in today's interview with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q04

Your personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R06

For the last few questions, I would like to speak with one of your parents or your guardian.

Administration (XADM) - Question identifier:XADM_Q06

Is one of your parents or guardian available?

1. Yes
2. No
3. Parent or guardian refuses to participate

Administration (XADM) - Question identifier:XADM_R07

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time.

Administration (XADM) - Question identifier:XADM_R08

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time. I would now like to try and find the best time to speak with one of your parents or guardian.

Administration (XADM) - Question identifier:XADM_R09

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time. I would now like to speak with one of your parents or guardian.

Administration (XADM) - Question identifier:XADM_R10

Hello, My name is ... I've just completed the main portion of the interview with ^FNAME. At this point I would like to ask you a few administrative questions to finish the interview.

Administration (XADM) - Question identifier:XADM_R11A

In 2010, ^FNAME responded to the Canadian Community Health Survey. At that time, you gave permission for ^DT_QUEBECHNE to link information from that survey to ^FNAME's health services information. You also gave us ^FNAME's provincial health number to assist in linking this information.

Administration (XADM) - Question identifier:XADM_R11B

In order to reduce the number of questions on today's survey, Statistics Canada would like to link information from this interview with ^FNAME's information from the 2010 Canadian Community Health Survey.

Administration (XADM) - Question identifier:XADM_Q11

The linked information will be kept strictly confidential and used only for statistical purposes.

Do we have your permission?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R12

Statistics Canada would like your permission to share the linked survey data, that is ^FNAME's information from today's interview and ^FNAME's information from the Canadian Community Health Survey, with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q12

Information from both surveys will be kept confidential and used only for statistical purposes.

Do you agree to share the linked information?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R13

Although you do not agree to link ^FNAME's information collected in today's interview to the 2010 Canadian Community Health Survey, we would like your permission to share only the information collected today with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q13

^FNAME's personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R14

Although you do not agree to share ^FNAME's linked survey information, we would like your permission to share only the information collected in today's interview with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q14

^FNAME's personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

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