SURVEY QUESTIONNAIRE

Dear Respondents,
Attached you will find a copy of the survey instrument
for our Research entitled “Effect of treatment regimen to the
coping mechanism of Diabetes Mellitus Type 2 patients.”
May we request you to accomplish the questionnaire to the
best of your ability. The information you would supply through
this questionnaire would help us very much toward the completion
of our study.
We will assure you that your responses will be kept
confidential. Thank you very much for your cooperation.
THE RESEARCHERS

Name:__________________________________________ (Optional)
Part 1: Respondent’s Profile
Direction: Please put a check mark (/) corresponding to your
answer on the space provided for.
Age:
18-21 ( ) 46-55 ( )
22-25 ( ) 56-65 ( )
26-35 ( ) 66-75 ( )
36-45 ( ) 76 above ( )

Gender:
Male ( ) Female ( )

Civil Status:
Single ( ) Married ( ) widower/r ( ) separated ( )

Gross monthly family income

4,000 and below ( ) 5,000- 9,000 ( )
10,000 and above ( ) Others _________

Educational Attainment
Elementary undergraduate ( )
Elementary graduate ( )
High school undergraduate( )
High school graduate ( )
College undergraduate ( )
College graduate ( )
 Occupation
Farmer ( ) Private employee ( )
Driver ( ) Vendor ( )
Government employee ( ) others specify _________

Part II: Type 2 Diabetes Mellitus coping mechanisms.

Direction: Please check the type of health management you do to

manage and maintain normal blood glucose level.

2.1 Diet

Items 5 4 3 2 1
Low calorie intake
Limitation of fatty foods
Low simple sugar (e.g. candy, cakes,
chocolate, honey, soft drinks, etc.)
Low salt intake
Limitation of caffeine (e.g. coffee,
energy drinks, soft drinks, tea,
alcohol, etc.)
Midnight snack
Supplements:
 Adequate intake of vitamin C
 Adequate intake of vitamin E
 Adequate intake of vitamin A
 Adequate intake of vitamin B12
 Adequate intake of zinc
 Adequate intake of magnesium
Increase fluid intake

The following interventions were recommended by Diabetes Center

of the Philippines, the Food and Nutrition Research Institute
(FNRI) and Department of Health.

2.2 Exercise

Items 5 4 3 2 1
I jog/ walk every morning
I go to gym for work out
I do light exercise before going to
bed
I do some light household chores
2.3 Treatment regimen to maintain blood glucose level.

Items 5 4 3 2 1
I take Oral Hypoglycemic Agent
I take herbal medicines (e.g.
onions, ampalaya, pandan leaves,
garlic, etc.)

2.4 Coping Strategies

Items 5 4 3 2 1
I visit my dietician when necessary
I go to health center for
consultation
I attend lecture regarding health
education of Diabetes Mellitus
I read magazine/book about Diabetes
Mellitus
I comply to my dietary regimen
strictly

2.5 Effective stress management

Items 5 4 3 2 1
Breathing exercises
Progressive relaxation therapy
Replace bad thoughts with good ones
(positive mind)
Enough rest

Part III: Perceived effects of treatment regimen to coping

mechanism of the patients.

Items 5 4 3 2 1
I am able to maintain my blood
glucose to normal level
I can manage to cope up with my
disease
I have an effective treatment
regimen

Certified true by:

SIGNATURE OVER PRINTED NAME (INTERVIEWEE)

Interviewed by:

SIGNATURE OVER PRINTED NAME (STUDENT)