pepper60
01-17-2008, 06:14 PM
Reply to: atlanta.fieldwork@gmail.com (atlanta.fieldwork@gmail.com?subject=Repondents%20 Needed%20for%20Health%20Study)
Study: Diabetes Study
Date: Wednesday January 23rd,2008 or Thursday January 24th,2008
Incentive: $100.00
Length: 90 minutes
Time: Various times available throughout the day
Please reply with your answers to the following questions:
Name: _____________
Age: ______________
Home Phone: ____________
Wk Phone: ______________
Cell Phone: _____________
(Please pass this e-mail on to friends or co-workers who you think may qualify)
1.Have you, yourself, of has any other member of your immediate family ever been diagnosed with diabetes that requires regular monitoring of the blood glucose level or not?
Yes.....
___Yourself
___Family Member… SPECIFY…
___ Spouse
___ Daughter
___ Son
___ Other (Specify) _______
_____ No
2.With which of the following types of diabetes have you been diagnosed?
____ Diabetes mellitus Type I, also called juvenile diabetes
____ Diabetes mellitus Type II
____ Some other type of diabetes
____ Don’t know
3.How do you currently treat your diabetes?
____ Insulin injections only
____ Insulin pump
____ Diabetes pills
____ Diabetes pills + insulin
____ Diet and Exercise
____ None
4.What one brand of blood glucose meter do you currently use most often to test your blood glucose at home?
____ CVS Brand
___HDI’s Tru-Track
___ Kroger
___ReliOn Ultima
___ Rite Aid
___ Walgreen Brand
___ Wal-Mart
___ Other Store Brand/Private Label (Specify) ______
Note: You will be asked to bring your meter to the focus group.
Study: Diabetes Study
Date: Wednesday January 23rd,2008 or Thursday January 24th,2008
Incentive: $100.00
Length: 90 minutes
Time: Various times available throughout the day
Please reply with your answers to the following questions:
Name: _____________
Age: ______________
Home Phone: ____________
Wk Phone: ______________
Cell Phone: _____________
(Please pass this e-mail on to friends or co-workers who you think may qualify)
1.Have you, yourself, of has any other member of your immediate family ever been diagnosed with diabetes that requires regular monitoring of the blood glucose level or not?
Yes.....
___Yourself
___Family Member… SPECIFY…
___ Spouse
___ Daughter
___ Son
___ Other (Specify) _______
_____ No
2.With which of the following types of diabetes have you been diagnosed?
____ Diabetes mellitus Type I, also called juvenile diabetes
____ Diabetes mellitus Type II
____ Some other type of diabetes
____ Don’t know
3.How do you currently treat your diabetes?
____ Insulin injections only
____ Insulin pump
____ Diabetes pills
____ Diabetes pills + insulin
____ Diet and Exercise
____ None
4.What one brand of blood glucose meter do you currently use most often to test your blood glucose at home?
____ CVS Brand
___HDI’s Tru-Track
___ Kroger
___ReliOn Ultima
___ Rite Aid
___ Walgreen Brand
___ Wal-Mart
___ Other Store Brand/Private Label (Specify) ______
Note: You will be asked to bring your meter to the focus group.