CONSENT FORM
Dear participants
I am DJUIMALA KAMAHA ELISABETH RICHNELLE a year three nursing students of HINTP carrying out a
research project title "KNOWLEDGE AND PRACTICES OF ADULT AGED 40YEARS AND OLDER ON THE
MANAGEMENT OF TYPE 2 DIABETES AT BONASSAMA DISTRICT HOSPITAL " .This is done to fulfill one of
the neccessary requirement to obtain "HIGHER NATIONAL DIPLOMA IN MEDICAL NURSING" (HND).. I
will love to get your thoughts on the questions found in this attached questionnaire about management
on diabetes type 2, in all honesty and liberty please note that you are free to withdraw out this study at
any time without any consequence .We assure you of outer most confidentiality.
Please if you are willing to take part in this study, please sign this form
Thanks.
Done at ....................................
Douala Signature of investigator..................
Signature of participants............
Passu vanel
QUESTIONNAIRE
INTRODUCTION : please tick the options that best fit your thoughts on management of
diabetes type II mellitus
SECTION A : SOCIO- DEMOGRAPHIC INFORMATION OF RESPONDENT
1. Gender: a) male. b) female
2. Age range:
a) 40-45years. b) 46-50years. c) 51-55years. d) 56-60years
3. Marital status:
a) married b) single. c) Divorced. d) widowed
4. Religion:
a) Christian. b) Muslim. c) Traditional. d)others
5. Level of education.
a) primary. b) secondary. c) university d) no formal education
6. Occupation
a) governement employee. b) private employee. c)student.
d) housewife e) not working at all
SECTION B : KNOWLEDGE ON TYPE 2 DIABETES MELLITUS
7. Have you ever heard about diabetes mellitus type II?
a) yes. b) No c) Maybe
[Link] yes what was the source of information?
a) friend. b) Television/radio. c)Health workers d) others.
[Link] is diabetes mellitus type II according to you?
a) A chronic disease in which blood glucose is too high because insulin is not produced or insufficient.
b) A condition people get from eating sweetened foods. c)Nosocomial infection.
d) I don't know
[Link] causes of diabetes mellitus type II do you know?
a) insulin resistance. b) Genetic factors.
c) lifestyle and environmental factors. d) age
11. Which of this following is not a common symptoms of diabetes type 2.
a) frequent urination. b) increased thirst.
c) weight gain. d)blurred vision
12. What are the possible risk factor for developing type II diabetes?
a) low carbohydrates intake b) high physical activity
c) obesity and sedentary lifestyle. d) eating only vegetables
13. Do you know about any complications of diabetes mellitus type II?
a) mental health issues. b) nerve damage
c) cardiovascular complications. d)kidney damage
14. How many days per week should a patient with type 2 diabetes engage in physical activity?
a) 3days. b)2 days. c)1 day. d) everyday
15. What type of exercises do a diabetic patient perform
a) swimming. b) Dancing. c)walking d) yoga
SECTION C : LIFESTYLE PRACTICES
[Link] are you managing diabetes type II?
a) Attending sessions with a registered dietitian. b) Engaging in physical exercises.
c) Following a specific meal plan d) Checking blood sugar level regularly.
17. Do you smoke?
a) Daily. b) occassionally. c) never. d) stopped
18. Do you drink alcool? If yes, how often.
a) Daily. b) occassionally. c) never. d) stopped
19. How often do you check your blood sugar?
a) daily. b) occasionally. c) every 3 months d) every 1 year
20. Do you take your prescribed diabetes medication regularly?
a) Yes. b) always c) sometimes. d) No
21. Which medication are you on?
a) Metformin. b) insulin. c) Mixtard. d) Actrapid
22. Do you get at least 6-8 hours of sleep per night?
a) Yes. b) always. c) sometimes d) No
23. Which lifestyle change is most recommended for managing type 2 diabetes?
a) Avoiding all carbohydrates. b) regular physical activity and balanced diet
c)Avoiding medications. d) eating only protein based meals
24. What challenges do you face in managing diabetes mellitus type II?
a) lack of support b) cost of healthcare
c)Dietary restriction. d) weight management