Questionnaire
Section A: Personal data
Gender: male [ ],
female [ ]
female [ ]
Age 15-24 [ ],
25-34 [ ], 45 and above [ ]
25-34 [ ], 45 and above [ ]
Marital status: single [
], married [ ], divorced
[ ], widow/widower [ ]
], married [ ], divorced
[ ], widow/widower [ ]
Educational status: primary [ ], secondary [ ], tertiary [ ], no formal education [ ]
Occupation: trading [
], farming [ ], civil servant
[ ], self-employed [ ]
], farming [ ], civil servant
[ ], self-employed [ ]
Section B: Health status
Do you check your blood sugar level? yes [ ], no [
]
]
If yes, how often do you check? Monthly [ ], 3 months interval [ ], 6 months interval [ ], one year interval [ ]
Have you been diagnosed with diabetes? Yes [ ], no [
]
]
If yes, how long ago were you diagnosed? Less than a year
[ ], 1 to 3 years ago [ ], 4-6 years ago [ ], 7 to 9 years ago [ ], 10 and above years ago [ ].
[ ], 1 to 3 years ago [ ], 4-6 years ago [ ], 7 to 9 years ago [ ], 10 and above years ago [ ].
Have you had any health problems due to diabetes? Yes [ ], no [
]
]
Section C: Awareness on the effects,
causes, prevention and treatment of diabetic retinopathy
causes, prevention and treatment of diabetic retinopathy
Are you familiar with the term Diabetic retinopathy? Yes
[ ], no [ ]
[ ], no [ ]
Do you know the causes of Diabetic Retinopathy? Yes [ ], no [
]
]
Are you aware it can be prevented? Yes [ ], no [
]
]
Are you aware it can be treated? Yes [ ], no [
]
]
Have you ever experienced any of these Diabetic symptoms?
Blurred vision [ ], floating spots
[ ], sudden loss of vision [ ], pain in the eyes [ ], cataracts [ ]
Blurred vision [ ], floating spots
[ ], sudden loss of vision [ ], pain in the eyes [ ], cataracts [ ]
Do you manage your blood sugar level? Yes [ ], no [
]
]
