Ask Dr. Litvin A Question

Thank you for visiting the Litvin Centers for Diabetes web site. Let us know what you think about our site by completing the following information.

By submitting your information, you agree that it will be governed by our PrivacyPolicy.

Please Note: The information provided by this site is for general background purposes and is not intended as a substitute for medical diagnosis or treatment by a trained professional. You should always consult your own physician about any healthcare questions you may have, especially before trying a new medication, diet, fitness program, or approach to health care issues.

Only messages that include an e-mail address will receive a response.

e-mail address:

* Required Field

Age:

Select Your Age ---------------------------------- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 * Required Field

Male     Female

Message Category:

Select a Category -------------------------------------------- Other Diabetes Information Web Site Comment * Required Field

Comments:

How did you hear about our site?

Select One Search Engines I'm a Patient Someone Referred Me Heard About LCD From Another Site Yahoo Yello Pages * Required Field

Please complete the following information, so we can better understand your condition.

I use the following to control my diabetes

Insulin injections

Insulin pump

Oral glucose tablets

Diet and/or exercise

Hypoglycemic or oral medication

To test your blood sugar what method, if any, do you use?

I do not test my blood sugar.

I test my blood sugar using visual strips.

I test my blood sugar with a meter.

I use both a meter and visual strips.

If you test your blood sugar, how often do you test?

Less than once a week

1-6 times per week

Once a day

Two times a day

Three times a day

Four or more times a day

Don’t test

Are you visiting this Web site because you:

Are at risk of developing diabetes?

Have diabetes?

Have a family member with diabetes?

Have a friend with diabetes?

Treat patients with diabetes?

Other

How often do you visit Web sites looking for diabetes-related information?

Once a week or more

2-3 times month

Once a month

2 to 6 times a year

Once year or less

Other

Why do you visit a diabetes Web site:

To answer a specific question on an as-needed basis

General information to see what’s new

Special offers/discounts/free stuff

See a favorite feature by a particular person/expert/community

Interactions with other people with diabetes such as chat rooms and bulletin boards

Other

Overall, how would you rate this Web site?

Excellent

Good

Neither good nor bad

Poor

How would you rate the usefulness of the information, tools, and features offered on this Web site?

Yes, extremely useful

Yes, very useful

Yes, somewhat useful

No, not very useful

No, not at all useful

If you were looking for diabetes-related information in the future, would you visit this Web site again ?

Yes, definitely would visit again

Yes, probably would visit again

Yes, might or might not visit again

No, probably would not visit again

No, definitely would not visit again

First Name:

Last Name:

Street
Address:

City:

State:

Zip Code:

Country:

Telephone: