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Diabetes Patient
Assessment Questionnaire
PATIENT
DATA
Name
______________________________________
Address
____________________________________
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Phone
number:
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Home
( ) ______________
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Work
( ) ______________
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Insurance
carrier _____________________________
ID # _______________________________________
Who is
your primary physician?
___________________________________________
Address
and phone number of physician, if known:
___________________________________________
___________________________________________
When
did you last see your physician about diabetes?
___________________________________________
Have
you been seen by a specialist in diabetes care?
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No
__ Yes __
If
so, please state the name of the specialist.
__________________________________
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Have
you had a dilated pupil eye exam?
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No
__ Yes __
Date of last exam ________
Results of exam: any signs of
retinopathy?
No __ Yes __
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Have
you received any diabetes education?
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No
__ Yes __
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If
yes, which topics?
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Nutrition
or diet info _____
Importance of exercise _____
Foot care _____
Blood glucose monitoring _____
Diabetes complications _____
Diabetes medications _____
Use of insulin _____
Duration of education program?
2 hours or less ____ 2-4 hrs ____
4-8 hrs ____
Several days ____ Other ________
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How
long have you had diabetes? ________ yrs
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Your
age or birth date ___________
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Please
mark the type of diabetes you have.
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Type
1 ____ Type 2 ____ Don't know ____
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Have
you met with a Certified Diabetes Educator (nurse, dietitian or
pharmacist) about your diabetes treatment?
How
do you feel about your diabetes care?
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Good
____ Average ____ Poor ____
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How
do you feel about working to improve your diabetes care?
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I
feel ready ____ I am not sure ____
I am a bit skeptical or need more
info ____
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Do
you have a Medic Alert tag or bracelet? No
__ Yes __
Do
you have a bathroom scale to weigh yourself weekly?
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No
__ Yes __
Has your weight changed in the past
few months?
No __ Yes __
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Do
you have a device to self-monitor blood pressure at home?
No __ Yes __
Do
you self-monitor blood glucose levels?
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No
__ Yes __
If yes, do you keep track of the
results of your blood glucose tests?
No __ Yes __
What meter do you use?
_____________________
How often do you test?
______________________
Have you been trained about how to
easily get a drop of blood?
No __ Yes __
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Do
you smoke? No __ Yes __
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If
yes, would you be interested in attending a smoking cessation
program?
No __ Yes __
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Do
you belong to the local affiliate of the American
Diabetes Association? No __ Yes
__
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If
no, would you like information about joining?
No __ Yes __
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Do
you belong to a local diabetes support group?
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No
__ Yes __
If no, would you like information
about a group?
No __ Yes __
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Would
you like any educational reading materials about diabetes?
No __ Yes __
Do
you frequently have "heartburn" or acid reflux problems?
No __ Yes __
Do
you feel bloated or nauseated after you eat a meal? No
__ Yes __
Are
you frequently constipated? No
__ Yes __
Do you have any problems with sexual
function?
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No
__ Yes __
If you are a man, do you have
erectile dysfunction (impotency)?
No __ Yes __
If you are a woman, do you have
vaginal dryness?
No __ Yes __
If you are a woman, do you have
frequent vaginal yeast infections? No __ Yes __
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Have
you been trained in preventative dental care?
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No
__ Yes __
Do you brush and floss at least
twice a day?
No __ Yes __
Do you see a dentist at least twice
a year?
No __ Yes __
Do you get a new tooth brush at
least every 2 weeks?
No __ Yes __
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Have
you been trained in preventative foot care?
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No
__ Yes __
Do you examine your feet daily? No
__ Yes __
Do you have a quality pair of nail
clippers?
No __ Yes __
Do you rub lotion on your feet each
night?
No __ Yes __
Do you have a mirror to help you see
all areas of your feet? No __ Yes __
Do you frequently have athlete's
foot?
No __ Yes __
Do you have fungal infections of
your toe nails?
No __ Yes __
Have you been trained as to how to
break in a new pair of shoes? No __ Yes __
Would you like me to test your feet
for neuropathy?
No __ Yes __
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Do
you take a daily multivitamin that is high in antioxidants?
No __ Yes __
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Would
you like information about the need for vitamins C and E, folic
acid, magnesium, zinc, selenium, chromium, calcium, B vitamins?
No __ Yes __
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Do
you take any "natural" or "herbal" remedies for
diabetes? No __ Yes __
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If
yes, please list: ___________________________
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Do
you suffer from any diabetes complications?
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No
__ Yes __
If yes, which ones?
_________________________
_________________________________________
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Please circle any of the following that you have:
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Neuropathy
in hands or feet
Retinopathy or other eye problems
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Kidney
problems
Heart problems
Frequent urination
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Skin
problems
Bladder infections
Frequently tired
|
Pain
in legs after walking
Other (please list)
___________________________
_________________________________________
_________________________________________
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Has
your physician checked the back of your neck for dark patches?
No __ Yes __
(The presence of dark patches is a symptom
of insulin resistance called acanthosis nigricans.)
Do
you ever have low blood sugar levels (hypoglycemia, insulin reactions)?
No __ Yes __
Do
you carry glucose tablets to treat low blood sugar?
Do
you own and have you been trained to use a Glucagon Emergency Kit?
No __ Yes __
LABORATORY
VALUES
Have
you had your hemoglobin A1c (HbA1c, glycosylated hemoglobin) level
measured?
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No
__ Yes __ Don't know __
If yes, what was the last value?
_______ %
When was it last measured?
________________
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What
was your last fasting plasma glucose value?
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Don't
know ____ or ______ mg/dL
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Have
you ever been tested for protein in your urine (microalbuminuria)?
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No
__ Yes __ Don't know __
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Have
you ever had ketones in your blood or urine?
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No
__ Yes __ Don't know __
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What
are the values for your blood pressure?
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Systolic
_____ Diastolic _____ Don't know ____
[Blood pressure goal is <130
(systolic)/85 (diastolic) mmHg]
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What
are your blood lipid (fat) values?
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HDL
_____ LDL _____ Total cholesterol _____
Triglycerides _____ Don't know ____
When were your blood lipid values
last tested?
___________________________________
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Please
state your weight: ________lbs.
Your height: ____ft. ____inches
(BMI can be calculated from these values
__________) [pharmacist will fill in]
If
you are a woman, have you had a bone density screening (for osteoporosis)?
No __ Yes __
TREATMENT
FOR DIABETES
Have
you met with a dietitian and had a nutrition program prescribed?
No __ Yes __
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If
yes, do you limit calories? No __ Yes __
If yes, do you count carbohydrates?
No __ Yes __
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Do
you consume alcohol? No __ Yes
__
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If
yes, how many drinks per day?
Beer ____ Wine ____ Liquor ____
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Do
you follow a prescribed routine exercise program?
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No
__ Yes __
If yes, for how long and how many
times a week?
_______________________________________
Type of exercise: Walking ____
Running ____
Weight training ____ Other
_______________
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Do
you inject insulin to treat your diabetes?
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No
__ Yes __
If yes, which type of insulin and
how much and how
often do you inject?
Insulin type ________ Daily number
of units _____
Injections/day _________
(Insulin types include NPH, Regular,
Humalog, Lantus, Ultralente, Lente or Mixtures)
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Do
you take any oral agents to treat your diabetes?
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No
__ Yes __
If so, circle the medications you
take and fill in the dose and how often you take them.
Glyburide (Glynase, Micronase,
DiaBeta), glipizide (Glucotrol or Glucotrol XL), or glimepiride
(Amaryl) __________________________________
Metformin (Glucophage)
______________________
Acarbose (Precose) or Miglitol
(Glyset)
__________________________________________
Pioglitazone (Actos) or
Rosiglitazone (Avandia)
__________________________________________
Repaglinide (Prandin)
________________________
Nateglinide (Starlix)
__________________
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Has
your pharmacist or doctor told you:
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How
and when to take your medications?
No __ Yes __
How to store your medications? No __
Yes __
Do you have any questions about your
medications?
No __ Yes __
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Do
you take any medications to treat high blood pressure?
No __ Yes __
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If
yes, please list the medication's name(s):
_________________________________________
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Do
you take any medications to treat high blood fats (cholesterol,
triglycerides)? No __ Yes __
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If
yes, please list the medication's name:
_________________________________________
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Do
you take any medications to treat diabetes complications?
No __ Yes __
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If
yes, please list the medication's name:
_________________________________________
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Do
you take any medications to treat any other conditions?
No __ Yes __
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If
yes, please list all of the medications:
__________________________________________
__________________________________________
__________________________________________
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OTHER
TOPICS
Please
list any other healthcare issues that you would like to discuss:
1.
_________________________________________
2.
_________________________________________
3.
_________________________________________
4.
_________________________________________
FOR
EDUCATOR’S USE:
TOPICS
THAT NEED ATTENTION:
TREATMENT
PLAN:
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Short-term
plan:
Next appointment
___________________________
Information
needed from physician:
_________________________________________
_________________________________________
Other:
Long-term
plan:
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Dates
of Interventions
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Time
Spent with Patient
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