This free survey is powered by
0%
Exit Survey
 
 
Sex?
 
Male
 
Female
 
 
 
Ethnicity?
 
White
 
Black
 
Latino
 
Asian
 
Arab
 
 
 
Is diabetes hereditary in your family?
 
Yes
 
No
 
 
 
What type of diabetes do you have?
 
Pre
 
One
 
Two
 
None
 
 
What age were you diagnosed?
 
1-12
 
13-25
 
26-35
 
36-45
 
45+
 
How well do you control your diabetes?
Poorly Adequate Very controled
 
 
 
How far away (In miles) are you from a super market?
 
1-5
 
5-10
 
11-15
 
16-20
 
25+
 
 
 
How many times a week do you go out to eat?
 
1-2
 
2-3
 
3-4
 
5+
 
 
 
Does your salary Affect food choices?
 
Yes
 
No
 
 
 
How many days a week do you exercise, for at least 30 minutes?
 
None
 
1-2
 
3-4
 
4-5
 
5-6
 
Everyday