Diabetes Users Survey

La Plaza can provide better diabetes information, if we know more about individuals who use La Plaza Diabetes Wellness Online Information.

Please take a few moments to answer the following questions in the form below and tell us about yourself. Information is confidential.

Thank you for assisting La Plaza.


1. Are you a Health Care Professional?

Yes No

2. Do you have diabetes?

Yes No

3. Do you have a relative or a friend who has diabetes?

Yes No

4. What is your sex?

Male Female

5. What is your age?

less than 15 16-21 22-30 31-40 41-50 51-65 65+

6. What is your ethnicity?

White Hispanic-American Native American

African-American Asian-American Other Citizenship

7. What is your annual income?

$0-5,000/yr $5,000-10,000/yr $10,000-15,000/yr $15,000-24,00/yr

$24,000-35,000/yr $35,000-45,000/yr $50,000/yr +

8. Where do you live?

Taos Questa Penasco Angel Fire Pilar

Red River Eagle Nest Vadito Santa Fe Albuquerque

Other Location:
City

State

Country

9. How long have you been using computers?

New User 1-6 Months 6 Months -1 Year

1-3 Years 3-5 Years 6-10 Years 10-20 Years

10. How long have you been using the Internet?

Never 1-6 Months 6 Months-1 Year

1-3 Years 3-5 Years 6-10 Years 10-20 Years

11. Where do you access La Plaza?

Home PC Friends PC

Library School La Plaza Telecommunity Center Community Center

Clinic/Hospital

Workplace

Other:

12. How did you hear about La Plaza?

Community Meeting Advertisements/Media Friends Business School La Plaza user or staff member





DWC
Homepage

Patient/Consumer
Information

Professional
Information

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