SEARCH Diabetes Eating Problem Survey (DEPS-R)

Form Approved 
OMB No. 0920‐0904 
Exp. Date 11/30/2014 

(affix label here) 
Patient ID
Number

Site

Sub-site

Sequential ID

SEARCH Diabetes Eating Problem Survey (DEPS-R) for age 10 and older

Do you take insulin?  Yes  No

if no, do not complete this form.

Living with diabetes can sometimes be difficult, particularly regarding eating and diabetes management. Listed below
are a variety of attitudes and behaviors regarding diabetes management. For each statement, check the ONE answer
that indicates how often this is true for you during the PAST MONTH.
Never

Rarely

Sometimes

Often

Usually

Always

1. Losing weight is an important goal to me.

0



1



2



3



4



5



2. I skip meals and/or snacks.

0



1



2



3



4



5



3. Other people have told me that my eating is out of
control.

0



1



2



3



4



5



4. When I overeat, I don’t take enough insulin to cover the
food.

0



1



2



3



4



5



5. I eat more when I am alone than when I am with
others.

0



1



2



3



4



5



0



1



2



3



4



5



7. I avoid checking my blood sugar when I feel like it is
out of range.

0



1



2



3



4



5



8. I make myself vomit.

0



1



2



3



4



5



9. I try to keep my blood sugar high so that I will lose
weight.

0



1



2



3



4



5



10. I try to eat to the point of spilling ketones in my urine.

0



1



2



3



4



5



11. I feel fat when I take all of my insulin.

0



1



2



3



4



5



12. Other people tell me to take better care of my diabetes.

0



1



2



3



4



5



13. After I overeat, I skip my next insulin dose.

0



1



2



3



4



5



14. I feel that my eating is out of control.

0



1



2



3



4



5



6. I feel that it’s difficult to lose weight and control my
diabetes at the same time.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing 
instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of 
information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays 
a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, 
including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; 
ATTN: PRA (0920‐0904). 
SEARCH 3 Cohort Study - SEARCH Diabetes Eating Problem Survey 11-01-10
© 2010 Markowitz, Butler, Volkening, Antisdel, Anderson, Laffel

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Never
15. I alternate between eating very little and eating huge
amounts.
16. I would rather be thin than to have good control of my
diabetes.

Rarely

Sometimes

Often

Usually

0



1



2



3



4



5



0



1



2



3



4



5



►Please answer one additional question.
17. I take less insulin than I should.

1

  Yes 2  No

FOR STUDY USE ONLY
Date Completed

Completed By
Month

Day

Year

Date Reviewed

Reviewer Code
Month

Day

Year

Date Entered

Data Entry
Code
Month

Day

Year

SEARCH 3 Cohort Study - SEARCH Diabetes Eating Problem Survey 11-01-10
© 2010 Markowitz, Butler, Volkening, Antisdel, Anderson, Laffel

Always

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