Join the TRUEcare™ Support Program by answering the short survey below. Answers to these questions will also help us to improve our product and service offerings to you, our valued customer. All information will be kept strictly confidential. Thank you for your interest and your confidence.

First Name: *

Last Name: *

Email Address: *

Address: *

Address 2:

City: *

State / Province: *

Zip / Postal Code: *

Country:

Home Phone Number:

1. Birth Date:

2. Please check ALL that apply *

Male

Female

Type 1

Type 2

Prediabetes

Gestational Diabetes

3. Years diagnosed with diabetes: *

4. Blood glucose testing frequency? *

# times per day = # times per week =

5. Are you a first-time meter user? *

Yes

6. If you answered no, to question #5 above, what is the brand name of your latest meter?

7. What type of medication do you currently use to manage your diabetes? *

None (diet/exercise only)

Pills

Insulin

8. Are your diabetes test strips fully or partially reimbursed through any of these plans? *

Yes, Medicare

Yes, Medicaid

Yes, Private insurance

No, I pay cash

9. Did you purchase a TRUE brand meter? *

Yes

10. Which TRUE brand meter did you purchase? *

TRUEresult

TRUE2go

TRUEtrack

TRUEread

Sidekick

Prestige IQ

I did not purchase a meter at this time

11. What most influenced your decision to purchase your TRUE brand meter?

Recommendation

Cost

Performance

Store brand

Packaging

Internet

Other

If Other:

12. Date of meter purchase:

13. Did someone recommend your TRUE brand meter to you? (Check all that apply)

Diabetes educator

Nurse practitioner

General practitioner

Endocrinologist

Friend or relative

Pharmacist

Other

If Other:

14. Where did you purchase your meter? *

Walgreens

CVS/pharmacy

Rite Aid Pharmacy

HEB Pharmacy

Other

If Other:

15. I understand that the information I've provided will be used only by Home Diagnostics, Inc. and its contracted third parties to give me helpful information about diabetes and related treatments, products and services, and for marketing and information purposes. Home Diagnostics, Inc. will not sell or transfer my personal information. *

I understand

I do not understand

* Answer Required

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