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Diabetes and Exercise Consent Form
This survey is designed to learn more about Diabetics and exercise
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Indicates required field
Biological Sex
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Male
Female
Name
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First
Last
Email
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Please list your diagnosis in relation to diabetes
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Type 1
Type 2
What was your age at diagnosis?
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What is your current age?
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What is your highest education level?
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High School
Vo-tech or skill training of any type
Some College
Bachlors degree
Masters degree
Doctorate (PhD) or MD
Other graduate degree
Select as many conditions you have experienced since your diagnosis
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Kidney disease
Circulatory/blood vessel issues
Neuropathy ( pain/decrese or lose of feeling in extremities)
Ulcers or sores on the skin
Eye conditions
Other
Not applicable
Do you most often experience hypoglycemia or hyperglycemia conditions?
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Hyperglycemia
Hypoglycemia
My blood sugar goes up and down
Did you do any type of regular exercise prior to diagnosis?
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Yes
No
If yes:
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Walking
Weightlifting
Running
Swimming
Biking
Yoga
Other
Not applicable
Are you currently exercising?
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Yes
No
If yes:
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Walking
Weight lifting
Running
Swimming
Biking
Yoga
Other
Not applicable
What is considered low blood glucose to you?
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100-90 mg/dl
90-80 mg/dl
80-70 mg/dl
70-60 mg/dl
60-50 mg/dl
50-less than 50 mg/dl
At what blood glucose level would you be concerned that you are in danger of a hypoglycemic episode?
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100-90 mg/dl
90-80 mg/dl
80-70 mg/dl
70-60 mg/dl
60-50 mg/dl
50-less than 50 mg/dl
Have you had a hypoglycemic episode that affected your daily routine? Where you unable to continue what you were doing prior to the episode?
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Yes
No
If so, what was your hypoglycemic reading that affected your daily routine?
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100-90 mg/dl
90-80 mg/dl
80-70 mg/dl
70-60 mg/dl
60-50 mg/dl
50-less than 50 mg/dl
N/A
Does the thought of controlling blood glucose while exercising give you anxiety/stress?
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Yes
No
Have you had low blood sugar during exercise?
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Yes
No
What was your low blood sugar during exercise?
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100-90 mg/dl
90-80 mg/dl
80-70 mg/dl
70-60 mg/dl
60-50 mg/dl
50-less than 50 mg/dl
N/A
Has low blood sugar prevented you from exercising?
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Yes
No
Has the thought of potentially low blood sugar before exercise given you anxiety?
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Yes
No
Has previous low blood sugar during exercise prevented you from future exercising?
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Yes
No
I do not exercise
Do you limit your exercise to avoid low blood sugar?
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Yes
No
I do not exercise
Does not knowing how to prepare for exercise and manage glucose levels during exercise give you anxiety?
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Yes
No
I do not exercise
How well of an understanding do you have on managing blood glucose for exercise?
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Very well
Well
Not well
I do not exercise
To avoid low blood sugar do you consume carbs prior to exercise?
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Yes
No
I do not exercise
To avoid low blood sugar do you consume carbs during exercise?
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Yes
No
I do not exercise
To avoid low blood sugar do you consume carbs after exercise?
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Yes
No
Do you keep your sugar at a certain level prior to exercise?
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Yes
No
If yes, what level do you attempt to keep your blood sugar at for exercise?
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100-150 mg/dl
150-200 mg/dl
200-250 mg/dl
250-300 mg/dl
N/A
Submit
Home Page: Florida Ultra Running Research
Abstracts
Current Research
About
Contact
Surveys Home Page
Diabetes and Exercise Consent Form