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N. Questionnaire-pose-de-pompe, Prénom : Date de naissance: Date de la pose de pompe à insuline 1

. Avez, Nombre de personnes au foyer: 7. Profession: Agriculteur exploitant Artisan, commerçant, chef d'entreprise Cadre, enseignant, médecin, universitaire, avocat, Employé Ouvrier Retraité Sans emploi

. Pratiquez-vous-une-activité-sportive, Combien de contrôles glycémique faites-vous par jour? 11 Quelle est votre dose de lantus? 12. Quelles sont vos doses de rapide? 13 Adaptation des doses d'insuline rapide oui/non 14 Si oui, adaptez-vous votre dose en fonction (plusieurs choix possibles): I. de votre glycémie avant le repas II. de votre glycémie 2h après le même repas le jour précédent III. de ce que vous mangez IV. de votre activité physique de la journée 15. Faites-vous des corrections? oui/non 16. Si oui, combien d'unités? 17. Faites-vous des rajouts d'insuline rapide? oui/non 18. Si oui: dans quelles circonstances? 19. Faites-vous des hypoglycémies? Oui/non 20 Comment vous resucrez-vous?

. Avez-vous-du-sucre-sur-vous-en, Craignez-vous les hypoglycémies? Oui/non 26. Pensez-vous pouvoir mourir d'une hypoglycémie? Oui/non 27. Existe-t-il une situation où vous faites le choix de rester en hyperglycémie pour éviter l'hypoglycémie? Oui/non 28, Si oui, dans quelle situation? Au travail Au volant Quand vous êtes seul(e) La nuit Pendant vos loisirs (sport, cinéma...)

. Avez-vous-du-sucre-sur-vous-en, Recherchez-vous l'acétone en cas de glycémie > 2 Comptez-vous les glucides dans votre alimentation? oui/non 16. Etes-vous satisfait de la pompe à insuline?