"I really appreciate being able to come here and meet people like me. I live in rural area so online support is fantastic."

Personal Details Form

Please fill out the following details about yourself so we can respond to you.

       
Name:
Age:
Gender:
Male Female
Email Address:
Ethnicity/cultural group:
(We need an email address to respond to you. If you do not have an address you can get a free address from sites such as Hotmail, Yahoo, ConnectSA)
 
NATIONAL DIABETES SERVICES SCHEME REGISTRATION
As this service is primarily funded under the National Diabetes Services Scheme (NDSS) we are required to collect your NDSS Registration number. The NDSS is an initiative of the Commonwealth Government administered by Diabetes Australia Ltd. The NDSS provides blood and urine testing strips, syringes and needles for special injection systems at subsidised prices to people who register for its benefits. You do nothave to be a member of Diabetes Australia to be eligible for the NDSS. It is free to register. 

Please select from the appropriate below and add your registration number if available.
Registered with NDSS YES         My number is:
Submitted form and awaiting number YES          Date submitted (if known):
I am a family member/support person and do not have access to the NDSS number YES        
I am not registered and have not submitted a form YES        
I do not know what the NDSS registration is YES        
  Registration with the NDSS is important. It is there for you to access reduced cost diabetes supplies and services. If you would like further information please either:
  • Contact your nearest Diabetes Australia Office
  • Follow this link for further information http://www.diabetesaustralia.com.au/ndss/
  • Or see your Doctor or Diabetes Educator who can arrange the forms for you
 

Address:
(optional, but it is helpful to us to know what country and area you are living in)

State:
(State is a mandatory field )
 

How long have you had diabetes?

Under 1 yr 1 - 5 yrs 5- 10 yrs 10- 20 yrs Over 20 yrs

Are you:

Type 1 Type 2 Other
(If Other, please give details such as family member, etc... )

 
Do you have regular contact with a Doctor and / or other health professional about your diabetes care?
 
Please select the problem area/areas closest to the problem/s you are contacting us about
Problem areas to select from:
New diabetes diagnosis
Denial and acceptance of diabetes/adjustment to diabetes
Diabetes Management - insulin
Diabetes Management - medication
Diabetes Management - diet and exercise
Diabetes Management - blood glucose monitoring
Weight management
Eating disorders
Mental Health and wellbeing
Depression
Anxiety and panic
Diabetes Complications
Relationships
Parenting a child with diabetes
Partner of a person with diabetes
Hypoglycaemia
Alcohol/drugs
Work and discrimination issues
Isolation and support
Information
Other medical problem
Other - please specify
and then please tell us about the problem or concern in your own words.
Give as much detail as you like