Type 2 Diabetes Management – Data Collection

Survey & Data Collection Form

Section 1: Participant Demographics

Name :

Contact No. :*

Age (in years) :

Gender :

Male

Female

Other

Marital Status :

Single

Married

Widowed

Divorced

Educational Qualification :

None

Primary

Secondary

Graduate

Postgraduate

Occupation :

Residence :

Urban

Rural

Semi-Urban

Section 2: Medical History

Duration of Diabetes (years) :

Type of Diabetes :

Type-1

Type-2

Family History of Diabetes :

Yes

Co-morbidities :

Hypertension

Heart Disease

Kidney Disease

Eye Problems

Others

Smoking :

Never

Occasionally

Current

Alcohol Consumption :

Yes

Section 3: Lifestyle Assessment

Physical Activity :

None

Light (e.g., walking)

Moderate (e.g., cycling)

Heavy

Exercise Duration (minutes/day) :

Sleep Hours per Day :

Diet Pattern :

Vegetarian

Non-Vegetarian

Mixed

Meals Per Day :

Junk Food Consumption :

Frequently

Occasionally

Never

Stress Level (1–10) :

Section 4: Self-Monitoring and Awareness

Do you monitor blood sugar at home? :

Yes

If yes, how often? :

Daily

Weekly

Monthly

Rarely

Do you own a glucometer? :

Yes

Attended diabetes awareness/education program? :

Yes

Section 5: Clinical / Lab Parameters

Blood Pressure (mmHg) :

Sugar :

Height (cm) :

Weight (kg) :

BMI :

Recent Complications :

Consent Statement :

I consent to provide the above information voluntarily for academic and research purposes. My identity will remain confidential, and the data will be used solely for analysis.

Signature of Participant :