Dear Diabetic patient,

I am a student at USC and is currently doing a feasibiliy study on electronic medical records for diabetic patient. For this research, I have created some questions. Your answers to these questions will be such a great help in our study. Thanks in advance for your help!

God Bless,

Felix

1) How many different health care providers do you visit in an average year? (Please choose one)
   0       1        2      3      More

2) male/female

3) age

4) How many days a year do you travel away from home?(Please choose one)
  0-7        7-14            14+

5) Do you travel overseas?
  Yes        No

6) Are your medical records consolidated?
  Yes        No                                

7) If yes, what form are your medical records in? (Please choose one)
  CD Internet based Paper Other

8) Do you carry your medical records with you?
  Yes          No

9) Would a service that retrieves and electronically consolidates your medical records interest you?
(Please choose one)
 Very much           Yes                Not At All                      

10) Do you use a PDA device (Palm Pilot) on a regular basis?
      Yes             No

11) Please indicated the diabetes type that best describes your circumstances:
   Type I          Type II         Other