The document describes designing a questionnaire to gather information about diabetes. It provides details on question types and order, including using screens and warm-up questions early, with more difficult and personal questions later. Rules for writing questions are also outlined, such as using clear wording and avoiding bias. Examples of diabetes-related questions are given covering demographics, symptoms, management, and complications.

1. Experiment No-1
Deslgn a questlonnaire using a word processing package to gather Informatlon about a
particular database.
Aim:
Design a questionnaire using a word processing package to gather information about a
particular database.
What is questionnaire ?
a research instrument consisting of a series of questions for
the purpose of gathering information from respondents.
Question sequence
A questionnaire
In general, questions should flow logically from one to the next. To achieve the best response
rates, questions should flow from the least sensitive to the most sensitive. from the more general
to the more specific.
There typically is a flow that should be followed when constructing aquestionnaire in regards to
the order that the questions are asked. The order is as follows:
1. Screens
2. Warm-ups
3 Transitions
4. Skips
5. Difficult
6. Classification
Sereen: Screens are used as a screening method to find out early whether or not someone
should complete the questionnaire.
Warm-ups: Warm-ups are simple to answer, help capture interest in the survey, and may not
even pertain to research objectives.
Transitlon: Transition questions are used to make different areas flow well together.
Skips: Skips include questions similar to "ifyes, then answer question 3. Ifno, then continue
to question 5,"
Diffieult: Difficut questions are towards the end because the respondent is in "response
mode" also, when completing an online questionnaire, the progress bars lets the respondent
know that they are almost done so they are more willing to answer more difficult questions.
Classillcaton:Classification or demographicquestionshould be at the end because typically
they can feel like personal questions which will make respondents uncomfortable and not
willing to finish survey.

2. BASIC RULES FORQUESTIONNAIRE ITEM CONSTRUCTION
"
"
o
Use statements which are interpreted in the same way by members of different
subpopulations ofthe population of interest.
Use statements where persons that have different opinions or traits will give different
answers.
Think of having an "open" answer category after alist of possible answers.
o
Use only one aspect of the construct you are interested in per item.
o
Use positive statements and avoid negatives or double negatives.
o
Do not make assumptions about the respondent.
o
Use clear and comprehensible wording, easily understandable for all educational
levels
1. Ethnic origin (check only one)
Use correct spelling, grammar and punctuation.
o White not Hispanic
Avoid items that contain more than one question per item (e.g. Do you like
strawberries and potatoes?).
Question should not be biased or even leading the participant towards an answer.
Black not Hispanic
o Asian or Pacific Islander
o Filipino
o American Indian/ Alaskan native
0 Other:
2. What category of age you belong to?
GENERAL BACKGROUND
Less than 12 year old
12 to 18 years
18 to 60 years
60 and above
3. Are you currently (check only one):
o Single
o Married
o Divorced
o Widowed
4. In general, would you say your health is?
o Excellent
o Good

3. o Fair
5. Compared to one year ago, how would you say your health is now? Is it:
o Much better than Iyear ago
o
o
o
o
o
Poor
o
Somewhat better now(than Iyear ago)
About the same as I year ago
6. How satisfied are you with your life in general?
Somewhat worse now (than I year ago)
Much worse now(than 1year ago)
o Very satisfied
o
Satisfied
o Neither satisfied nor dissatisfied
o Very dissatisfied
7. In general, would you say your mental health is:
o Excellent
Very good
Good
Fair
o Poor
8. Thinking about the amount of stress in your life, would you say that most days are:
o Not at all stressful
Not very stressful
A bit stressful
o Quite a bit stressful
o Extremely stressful
9. Please indicate below which chronic condition(s) you have:
Diabetes
o Asthma
Emphysema or COPD
o Other lung disease Type of lung disease:
o Heart disease Type of heart disease:
o Arthritis or other rheumatic disease specify type:
o Cancer Type ofcancer:
o Other chronic condition specify:
SYMPTOMS

4. 10. To begin, do you have diabetes that has been diagnosed by a health professional?
11. Have you ever been diagnosed with diabetes?
12. Do anyone with a parent or sibling with diabetes in your family?
60
50
13. Do you check your BMI score?
40
30
20
Yes
o No
10
14. What is your BMI score?
0
Yes
o No
SL.no.
Yes
o No
o Yes
o No
Thin(<18) normall[18-24) over weight(24-30) Obese(>30)
Activity
15. Mark the appropriately according to question for symptoms and complications you may have
experienced as a result of having diabetes.
Do you feel thirsty, excessive
urination and weight loss?
Yes
20
No
10
sometimes

5. 2
3
4
5
6
7
8
9
10
12
13
14
15
In the past 12 months, did you
ever have to visit an emergency
room because of low blood
sugar(hypoglycemia)
Have you ever had any of the
following conditions diagnosed
by ahealth professional: diabetic
eye disease or diabetic
retinopathy?
Partial or complete blindness?
Cataracts?
Glaucoma?
Protein in your urine?
Kidney failure?
Nerve damage or neuropathy?
Heart disease (for example.
angina. heart attack)?
High blood pressure?
Stroke or mini-stroke?
Poor circulation in the feet or
legs?
Gangrene and/or amputation?
Problems with your gums?
16. Do you know the kind ofdiabetes you have?
o Yes
CLINICAL INVESTIGATION
o No
17. What kind ofdiabetes do you have?
o Type I(juvenile diabetes-by birth)
o Type II(as adult onset diabetes)

6. o Other (other than during pregnancy)
18. How old were you when you were first diagnosed with diabetes?
o Less than 12 year old
o
o 60 and above
fasting
12 to 18 years
19. What was reported value of glucose level in first examination?
After meal
18 to 60 years
Yes
o No
HbAlc Score
7 to 9
Glucose level
Less than
9 to 12
<60
20. Has a health professional ever given you an "HbAlc" test, also known as a glycosylated
hemoglobin test? "Hbalc" test is a measure of average blood sugar level over the past three
months.
(Please select the number below)
60-100
22. What was reported valve of HbA Ic in first examination?
>100
21. How many times in the past 12 months have you had your "HbAle" (glycosylated
hemoglobin) measured by a health professional?
More than 12
Glucose level
10
<100
100-160
>160
Tick your matching value
23. During the past week even if it you don't suffering from these. How much time did you
carried out the following?

7. o Other (other than during pregnancy)
18. How old were you when you were first diagnosed with diabetes?
o Less than 12 year old
12 to 18 years
o 60 and above
fasting
18 to 60 years
19. What was reported value of glucose level in first examination?
After meal
o Yes
o No
20. Has a health professional ever given you an "HbAlc" test, also known as a glycosylated
hemoglobin test? "Hbale" test is a measure of average blood sugar level over the past three
months.
HbAlc score
7 to 9
Glucose level
(Please select the number below)
Less than 7
<60
22. What was reported valve of HbA le in first examination?
60-100
>100
21. How many times in the past 12 months have you had your "HbAle" (glycosylated
hemoglobin) measured by ahealth professional?
9 to 12
More than 12
Glucose level
10
<100
100-160
>160
Tick your matching value
23. During the past week even if it you don't suffering from these. How much time did you
carried out the following?

8. (Please circle one number for each question)
SI. No Activity
1.
2
3.
4.
6.
SI.No.
2
Health
3.
professional
check your blood
pressure at yours
diabetes
appointmnents
Blood
related
cholesterol
checked by a health
professional
Health professional
checked your feet
for any scores or
irritations
An eye exam where
the pupils of your
eyes were dilated
Health professional
measured your
weight on a scale
Health professional
measured your renal
creatine level
Test
Never
HbAlc
0
0
0
Bloodpressure
Rarely
Bloodcholesterol
Sometimes
2
2
2
2
2
Often
3
3
3
3
3
3
24. Write the appropriate figures from your tests report you may have been given by a health
professionalto help monitor your diabetes:
Always
Report
4
4
4
4
4

9. 4.
5.
6.
SI.No
MANAGEMENT OF DIABETES
1.
2
25. During the past week. even if it was not a typical week for you, how much total time (for the
entire week ) did you spend on each of the following? please circle one number for each
question)
3.
5
6.
Activity
Bodyweight
BMI
Stretching
strengthening
exercises (range of
motion using weights
etc...)
Creatinine level
Walk for exercise
bikes)
Swimming or aquatic
exercise
Other
Bicycling (including
stationary
Other
exercise
or
specify
aerobic
exercise equipments
(stair master. rowing.
exercise
skiing machine etc...)
aerobic
None
0
Less than 30-60
30 min/ min/wk
week
1
1
2
2
2
2
2
2
1-3hrs/wk More than
3hrs/wk
3
3
3
3
3
3
4
4
4
4
4
4

10. 26. Did you taken any measures to control glucose level within limits after your increase blood
glucose level?
27. What type of measures taken?
o
o Exercise
o
o Fitness facilities or programs
o
Yes
o
No
o Smoking cessation programs
o
Diet control
o
Stress management programs
28. Which of the following health professionals or practitioners do you consider most
responsible for treating your diabetes?
o Family doctor or general practitioner
o
Did not use any services or programs to help manage diabetes
Diabetes centre
o Diabetes educator
Other medical doctor or specialist
Nurse or nurse practitioner
o Pharmacist other health professional
No health professionalresponsible for treating diabetes
o Acomplementary or alternative health care practitioner such as anaturopath or herbalist
29. In the past 12 months, did you ever experience any difficultiesgetting the routine or ongoing
care you needed for your diabetes?
Yes
o No
30. Currently, are you taking prescription medication including medications taken for diabetes?
Please include any pills, needles, liquids or inhalers that have been prescribed by a health
professional for any health condition.
Yes
No
31. Currently. how many different types of prescription medications are you taking? Please
include any pills, needles, liquids or inhalers that have been prescribed by a health professional
for any health condition.
One

11. o Two
o Three to four
o Five or more
32. Have youever taken insulin injections for your diabetes?
o Yes
o No
33. Thinking back to when you were first diagnosed with type H diabetes, how long was it
before you started insulin injection?
o Less than I year
o lyear to less than 2years
2 or more years
o Never
34. Do you currently take insulin injections for your diabetes?
o Yes
o No
35. Currently do you take any herbalor naturopathic remedies to treat your diabetes?
o Yes
o No
36. Has a doctor or other health professional ever discussed the complications of diabetes with
you?
Yes
o No
37. Whether your doctor or other health professionals may have discussed with you to help
control your risk factors for management of diabetes?( please circle the numbers below that
describes how many points you match to )
I) Changing the type
or amount of food you
eat to help control
your diabetes
S)To stop smoking
cigarettes.cigars or
pipes
2) Participating in
physical activity or
exercise to help you
6) Limiting alcohol
consumption to help
you control your
diabetes
3) Controlling or 4) Stress management
losing weight to help with you
you control your
diabetes
7)Recommended
monitoring your blood
sugar at home
8) blood pressure at
home using a home
blood
monitor
pressure
control your diabetes

12. 9
2
8
7
4
6
4
3
2
1
S.No.
3.
1 2
Statements
3
38. We have prepared series of statements related to how involved you are in thinking about or
making decisions about your diabetes and diabetes care. Please say whether you strongly agree.
agree, disagree or strongly disagree with each of the following statements:-
I know what each
of my prescribed
medications do
Iam confident that I
can follow through
On medical
treatments I need to
do at home
4
nature and causes of
my diabetes
understand the 0
I know how to
prevent further
problems with my
Strongly
agree
6
Agree
1
7
Disagree
2
2
8
2
2
Column2
Column1
Strongly
disagree
3
3
3
3

13. diabetes
39. Overall, how much does your diabetes effect your life ?
Not at all
A little bit
o Moderately
o Quite a bit
o Extremely
40. Do you agree to share the linked information?
Result:
Yes
o No
41. The linked information will be kept strictly confidently and used only for statistical purposes.
Do we have your permission?
o Yes
No
Thus we studied to design aquestionnaire using word processing package.