This free survey is powered by
  1. Surveys
  2. 2017
  3. February
  4. M
  5. Mhealth survey
0%
Questions marked with a * are required Exit Survey
 
 
* Who told you that you had Type II Diabetes? 
 
Doctor
 
Nurse
 
Health/Community
 
I don't not know
 
 
 
* How do you store the insulin vials you are currently using (up to 2 week suppy) 
 
Room Temperature
 
Refrigerator
 
Freezer
 
Under Sunlight/Near Window
 
Anywhere
 
Do you keep your pen at room temperature after the first use?
 

 
 
 
* How do you dispose your used insulin pens? (select all that apply) 
 
Sealable & Puncture Resistant Container
 
Sharp Container
 
Drop Off site in the community
 
Open trashcan
 
On the ground
 
Other
 

 
 
 
* After diagnosis, have you been seen by a health workers? 
 
Yes
 
No - answer question below
 
Do you need the contact information of a health worker or PHC near you?
 

 
 
 
* Do you reuse your insulin pen needles? 
 
Yes
 
No
 
Sometimes
 
Have you ever shared your pen with others?
 

 
 
 
* Are you compliant with the disposable insulin pen reigmen?

 
 
Yes
 
No

 
 
Contact Information
* First, Last Name  : 
* Age  : 
* Sex  : 
 
 
 
* DATE Survey Taken 
MonthDayYear
  
 
 
 
GPS: What African state are you in? 
 
 
 
* When where you diagnosed?
MonthDayYear