Depression Self Assessment

Cheyenne Ledbetter
The Effect of Depressive Symptoms on Type One Diabetes
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Name: 


A red asterisk (*) indicates required questions.

  1. Email Address*


  1. Do you play a sport? Extracurricular activities?*
    Yes
    No


  1. Age*
    13
    14
    15
    16
    17


  1. At what age were you diagnosed with diabetes?*
    Ages 1-3
    Ages 4-6
    Ages 7-9
    Ages 10-12
    Ages 13-14
    Ages 15-17


  1. How frequently do you check your sugar when you are angry and have had a stressful day?*
    1-2
    3-4
    5-6
    7-8
    9 or more


  1. Do you experience any of the following symptoms?
    (check all that apply)*
    Little interest or pleasure in doing things
    Feeling hopeless
    Trouble falling asleep, staying asleep, or waking up
    Feeling tired or having little energy
    Poor appetite or overeating
    Feeling bad about yourself and seeing yourself as a failure
    Trouble concentrating on things
    Moving slowly or being restless and fidgety
    Thoughts that you would be better of dead
    Thoughts of harming yourself/killing yourself


  1. People judge you because you have diabetes.*
     
      1 2 3 4 5  
    Strongly disagree  Strongly agree


  1. You are diagnosed with depression.*
    Yes
    No


  1. I have harmed myself intentionally.*
    Yes
    No


  1. How many times have you been sick in the past month?*
    1-2
    3-4
    5-6
    7-8
    9 or more.


  1. How do you take your insulin?  *


  1. Which insulin types do you take?
    (check all that apply)*
    Novolog
    Humalog
    Levemir
    Lantus
    Apidra
    Lispo
    Aspart
    Glulisine
    Humilin
    Novolin
    Velosulin
    NPH
    Lente
    Ultralente
    Humuilin 70/30
    Novolin 70/30
    Novolog 70/30
    Humulin 50/50
    Humalog mix 75/25


  1. What type of meter do you use?
    Accu Check
    One Touch
    Freestyle
    Medtronic
    ReliOn
    Bayer
    True2go
    Wave Sense
    Insuling pump monitor
    Other





Amanda Baskett