Diabetes Assessment | Fidelis Care

This short survey will only take a few minutes to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

How would you rate your level of overall health and well-being?*

Do you check your blood sugar levels regularly?*

Yes
Somewhat
No
I don’t need to check my blood sugar because it is not a part of my treatment plan

Please let us know why you are not checking your blood sugar levels regularly.*

(Please select all that apply)

I can't afford the supplies
I don't like to prick myself
It will not make a difference in my health state
I forget
I ran out of supplies
Other

You selected "other", why else are you not checking your blood sugar levels regularly?*

Do you follow the diet given by your doctor or diabetes specialist?*

Yes
Somewhat
No

Please let us know why you are not following your diet*

(Please select all that apply.)

I can't afford healthy food
It will not make a difference in my health state
I don't know what foods to eat to improve my health
Other

You selected "other", why else are you not following your diet?*

Have you been going to your doctor appointments?*

Yes
Most of the time
Sometimes
No

Please let us know why you haven't been going to your doctor appointments*

(Please select all that apply.)

Transportation issues
Childcare issues
I forget
I cannot get off from work
I have problems making appointments
Other

You selected "other", why else have you not been going to your doctor appointments?*

Do you take your diabetes medication as prescribed?*

(e.g. insulin, tablets)

Yes
Somewhat
No

Please let us know why you are not taking your medication as prescribed*

(Please select all that apply.)

I can't afford the prescription
I don't like the side effects
I forget
I ran out
I am having trouble contacting my provider
It will not make a difference in my health state
Other

You selected "other", why else are you not taking your medication as prescribed?*

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