CheckMate DDI — Insulin Adherence & Safety Monitor

Patient Assessment Form

Your Health Assessment

All information is processed locally in your browser and is never stored or transmitted.

I.Enter data

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II.View results

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III.Get your plan

§1

Patient biometric data

HbA1c Level (mmol/mol)

Glycated haemoglobin — target: <53 mmol/mol

Body Weight (kg)

Age (years)

Duration on Insulin Therapy (months)

§2

Sex / Gender

Employment Status

Other Chronic Health Conditions

e.g. cardiovascular disease, CKD, hypertension, neuropathy

§3

MARS · SATMEDQ

Enter your scores manually, or use the built-in questionnaire calculators to calculate them right here. Your results will auto-fill the fields below.

MARS Score (0–10)

Medication Adherence Report Scale — 10-question adherence scale

0 = Never adheres10 = Always adheres

SATMEDQ Score (0–100%)

Satisfaction with Medicines Questionnaire — 17-question satisfaction scale

0% = Very dissatisfied100% = Very satisfied

§4

Select all that apply

Select all medications you currently take alongside your insulin therapy. This enables drug-drug interaction screening.