Evaluation scheme for progress along and satisfaction with the Sensor ...

Evaluation scheme for progress along and satisfaction with the Sensor Experience Pathway with MiniMed™ 640G Patient’s First name/ family name Parent ‘s First name/ family name Physician’s First name/ family name Completion date

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PATIENT – Mark the smiley corresponding to the answer Are you satisfied with your therapy? Do you trust the system you are currently using? (MiniMed 640G) Is this system easy for you to use? Did you get clear and complete info from your physician on how to use this system? Are you willing to go on using this system over the next few months?

Evaluation scheme for progress along and satisfaction with the Sensor Experience Pathway with MiniMed™ 640G Patient’s First name/ family name Parent ‘s First name/ family name Physician’s First name/ family name Completion date

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PARENT– Mark the smiley corresponding to the answer Is your son/daugther satisfied with his/her therapy? Does your son/daughter trust the system he/she is currently using? (MiniMed 640G)

Does your son/daughter find this system easy to use? Did your son/daughter get clear and complete info from his/her physician on how to use this system? Is your son/daughter willing to go on using this system over the next few months?

Evaluation scheme for progress along and satisfaction with the Sensor Experience Pathway with MiniMed™ 640G Patient’s First name/ family name Parent ‘s First name/ family name Physician’s First name/ family name Completion date

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PHYSICIAN – Mark a single box per row – Page 1 of 2 Skills acquired by the patient while managing his/her therapy with the MiniMed 640G integrated system Time of continuous use of the sensor by the patient Hypo events reduction

0%

< 30% 30-49%

DAY NO

YES

50-69% 70-99% 100%

NIGHT NO

Autonomy in device data download Number of sticks per day Ability to fine tune his/her own therapy based on real time CGM information

______ / day

YES

Evaluation scheme for progress along and satisfaction with the Sensor Experience Pathway with MiniMed™ 640G Patient’s First name/ family name Parent ‘s First name/ family name Physician’s First name/ family name Compiling date

………./………../………………

PHYSICIAN – Mark one single box per row – page 2 of 2 Calibration well done?

Use of basal rate change?

YES

NO

YES

NO

YES

NO

YES

NO

Use of different bolus types? Hypoglycemia threshold fits to patient?