Diabetes Health Pump Survey

Diabetes Health would like to know how you feel about insulin pumps. We will use your input as the basis for a future article about pumping attitudes.

Please use this survey to describe your feelings about pumping.

The survey is completely anonymous, and no personal data is collected. Thanks for your participation.

First, tell us if you use a pump or not:

	I use a pump
	I use multiple daily injections

1. I worry that my pump might malfunction.

	True
	False

2. My pump has malfunctioned.

	True
	False

3. I have a problem with my sets crimping.

	True
	False

4. When calculating my insulin dose, I

	Just guess and wing it.
	Estimate my carbs and dose accordingly.
	Weigh my food exactly and calculate very accurately.

5. The insulin that I use is

	Regular
	Humalog
	Novolog
	Apidra

6. The time that I bolus is

	After I eat.
	When I eat.
	Ten minutes before I eat.
	Thirty minutes before I eat.
	It depends on my glucose level.

7. The number of times that I test my blood sugar daily is

	1-2
	3-4
	5-6
	7-8
	9 +

8. I've been in better shape emotionally since going on the pump.

	True
	False

9. I use a continuous glucose monitor.

	True
	False

10. I don't use a continuous glucose monitor because

	I can't afford one.
	I don't think it would help me.
	I don't want it attached to me.
	Not Applicable.

11. The pump has turned out to be more work than injections.

	True
	False

12. There are features that I wish the pump manufacturers provided on my pump. If yes, please describe.

	Yes
	No

1. I tried the pump and then went back to multiple daily injections.

	True
	False

2. I'd like to be on the pump but:

	I can't afford it
	My doctor won't prescribe it
	Not Applicable

3. I am not on the pump because:

	I don't like being hooked up to a machine.
	The pump is too public and obvious.
	I think it would malfunction.
	It's too hard to use.
	It's no better for you than multiple daily injections.
	I don't want to count carbs.
	I don't want to test that often.
	Inertia: I just haven't gotten around to it.
	I can't afford a pump.
	My partner doesn't want me to wear a pump.
	A pump would be too inconvenient.
	Not Applicable.

4. The number of times that I test is:

	1-2
	3-4
	5-6
	7-8
	9 +