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...............................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
11. Nausea or vomiting? .........................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
12. Abdominal pain?................................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
13. Frequent urination at night? Do you have
to get up to urinate 3 or more times a night?………......................... 􀁔 No 􀁔 Yes 􀁔 Don’t know
14. Severely high blood sugar
(blood glucose readings of 300 mg or higher?) ……......................... 􀁔 No 􀁔 Yes 􀁔 Don’t know
15. Morning headaches?..........................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
4
In the PAST WEEK, did you ever have any of the following symptoms…
16. Nightmares?.......................................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
17. Night sweats?.....................................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
14. Lightheadedness?...............................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
18. Shakiness or weakness?.....................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
19. Intense hunger?..................................................................................􀁔 No 􀁔 Yes 􀁔 Don’t know
20. Times when you passed out fainted or https://www.51lunwen.org/mgzuoye/lost........................................􀁔 No 􀁔 Yes 􀁔 Don’t know
consciousness, even for a short time?
Daily Activities
During the past 4 weeks, how much... (Circle one)
Not Quite Almost
at all Slightly Moderately a bit totally
1. Has your health interfered with
your normal social activities with family,
friends, neighbors or groups?..............................0 1 2 3 4
2. Has your health interfered with
your hobbies or recreational activities?..............0 1 2 3 4
3. Has your health interfered
with your household chores?..............................0 1 2 3 4
4. Has your health interfered with
your errands and shopping?................................0 1 2 3 4
Your Glucose Testing
1. Do you have a machine to measure your blood sugar (glucose) level? 􀁔 Yes 􀁔 No
2. On how many days in the last week did you test your blood sugar level? (If you were sick in the last week,
think of the most recent 7 days when you were NOT sick)
________ days
3. On days that you test your blood sugar, how many times do you test on average? _______ times
5
Physical Activities
During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following? (Please circle one number for each question.)
less than 30-60 1-3 hrs more than
none 30 min/wk min/wk per week 3 hrs/wk
1. Stretching or strengthening exercises
(range of motion, using weights, etc.)................0 1 2 3 4
2. Walk for exercise................................................0 1 2 3 4
3. Swimming or