Assessment Date

In general, my Present quality of life is:

If I did not have diabetes, my quality of life woud be:

If I did not have diabetes, I would enjoy my leisure activities:

My leisure activities are

Are you currently working, looking for work or would you like to work?

If I did not have diabetes, my work life would be:

For me, having a working life is:

If I did not have diabetes, local or long distance journeys would be:

For me, long distance journeys are:

Did you ever go on holiday or want to go on holiday?

If I did not have diabetes, my holidays would be:

For me, holidays are:

If I did not have diabetes, physically I could do:

For me, how much I can do physically is:

Do you have any family/relatives?

If I did not have diabetes, my family life would be:

My family life is

If I did not have diabetes, my friendships and social life would be:

My friendships and social life are:

Do you have a close personal relationship (e.g husband/wife, partner)?

If I did not have diabetes, my closest personal relationship would be:

For me, having a close personal relationship is:

Do you or would you like to have a sex life?

If I did not have diabetes, my sex life would be

For me, having sex is:

If I did not have diabetes, my physical appearance would be:

My physical appearance is:

If I did not have diabetes, my self-confidence would be:

My self-confidence is:

If I did not have diabetes, my motivation would be:

My motivation is:

If I did not have diabetes, my future would be

My feelings about the future are:

If I did not have diabetes, my financial situation would be

My financial situation is:

If I did not have diabetes, my living conditions would be

My living conditions are:

If I did not have diabetes, I would have to depend on others when I do not want to:

For me, not having to depend on others is:

If I did not have diabetes, my freedom to eat as I wish would be:

My freedom to eat as I wish is:

If I did not have diabetes, my freedom to drink as I wish (e.g. fruit juice) would be:

My freedom to drink as I wish is:

Any other ways in which diabetes and its management and any complications affect your quality of life: