Diabetic Support Group Application Form

Full Name:

Age:

Gender:
Select One.. Male Female Choose Not to Say

Section 1: Contact Information

Phone:

Email:

Mailing Address:
Your physical address here.

Preferred Method of Contact:
Select One... Phone Email Physical Mail

Section 2: Medical Information

Type of Diabetes:
Select One... Type 1 Type 2 Gestational Other (please specify below)

If other was selected above, please state:

Date of Diagnosis:

Current Medications:
List all current medications.

Insulin Treatment:
Select One... Insulin Pump Injections Other (please specify below)

If other was selected above, please state:

Other Medical Conditions (if any):
List all other medical conditions you may have.

Allergies (if any):
List all allergies you may have.

Section 3: Support Group Preferences

What are your expectations from the support group?
Please list your expectations.

How frequently would you like the support group to meet?
Select One... Weekly Bi-Weekly Monthly Other (plece specify)

If other was selected above, please state:

Preferred Meeting Days:
Select One... Monday Wednesday Thursday Sunday

Preferred Meeting Time:
Select One... Morning Afternoon Evening No Preference

Would you be interested in guest speakers or experts attending the support group sessions?
Select One... Yes No

Are you comfortable sharing your experiences and insights with the group?
Select One... Yes No Unsure

Do you have any specific topics or areas of focus that you would like the support group to address?
Please list any topics here

Do you have any suggestions or additional comments
Comments or Suggestions?

Section 4: Survey Questions

Please rate the following statements.

The support group should provide a safe and confidental environment for sharing experiences and concerns
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

I am interested in learning about new diabetes management techniques and technologies
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

I would like the support group to offer educational resources on nutrition and meal planning
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

Peer support and empathy are important aspects of a support group.
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

I would like the support group to organize social activities and outings.
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

I would be interested in participating in fundraising or advocacy initatives related to diabetes
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

The support group should provide resources and information on community events and workships related to diabetes.
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree

The support group should have an online forum or platform for ongoing communication between meetings.
Select One... 1 - Strongly Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree