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 Diabetes Patient Assessment Questionnaire

PATIENT DATA

Name ______________________________________

Address ____________________________________

Phone number:	Home ( ) ______________
	Work ( ) ______________

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?

No __ Yes __ If so, please state the name of the specialist. __________________________________

Have you had a dilated pupil eye exam?

No __ Yes __ Date of last exam ________ Results of exam: any signs of retinopathy? No __ Yes __

Have you received any diabetes education?

	No __ Yes __
		If yes, which topics?
	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 ________

 

How long have you had diabetes? ________ yrs

Your age or birth date ___________

Please mark the type of diabetes you have.

Type 1 ____ Type 2 ____ Don't know ____

Have you met with a Certified Diabetes Educator (nurse, dietitian or pharmacist) about your diabetes treatment?

No __ Yes __

How do you feel about your diabetes care?

Good ____ Average ____ Poor ____

How do you feel about working to improve your diabetes care?

I feel ready ____ I am not sure ____ I am a bit skeptical or need more info ____

Do you have a Medic Alert tag or bracelet? No __ Yes __

 

Do you have a bathroom scale to weigh yourself weekly?

No __ Yes __ Has your weight changed in the past few months? No __ Yes __

Do you have a device to self-monitor blood pressure at home? No __ Yes __

Do you self-monitor blood glucose levels?

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 __

Do you smoke? No __ Yes __

If yes, would you be interested in attending a smoking cessation program? No __ Yes __

Do you belong to the local affiliate of the American
Diabetes Association? No __ Yes __

If no, would you like information about joining? No __ Yes __

Do you belong to a local diabetes support group?

No __ Yes __ If no, would you like information about a group? No __ Yes __

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?

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 __

Have you been trained in preventative dental care?

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 __

Have you been trained in preventative foot care?

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 __

Do you take a daily multivitamin that is high in antioxidants? No __ Yes __

Would you like information about the need for vitamins C and E, folic acid, magnesium, zinc, selenium, chromium, calcium, B vitamins? No __ Yes __

Do you take any "natural" or "herbal" remedies for diabetes? No __ Yes __

If yes, please list: ___________________________

Do you suffer from any diabetes complications?

No __ Yes __ If yes, which ones? _________________________ _________________________________________

 

	Please circle any of the following that you have:
	Neuropathy in hands or feet Retinopathy or other eye problems Kidney problems Heart problems Frequent urination Skin problems Bladder infections Frequently tired Pain in legs after walking Other (please list) ___________________________ _________________________________________ _________________________________________

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?

No __ Yes __

Do you own and have you been trained to use a Glucagon Emergency Kit? No __ Yes __

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LABORATORY VALUES

Have you had your hemoglobin A1c (HbA1c, glycosylated hemoglobin) level measured?

No __ Yes __ Don't know __ If yes, what was the last value? _______ % When was it last measured? ________________

What was your last fasting plasma glucose value?

Don't know ____ or ______ mg/dL

Have you ever been tested for protein in your urine (microalbuminuria)?

No __ Yes __ Don't know __

Have you ever had ketones in your blood or urine?

No __ Yes __ Don't know __

What are the values for your blood pressure?

Systolic _____ Diastolic _____ Don't know ____ [Blood pressure goal is <130 (systolic)/85 (diastolic) mmHg]

What are your blood lipid (fat) values?

HDL _____ LDL _____ Total cholesterol _____ Triglycerides _____ Don't know ____ When were your blood lipid values last tested? ___________________________________

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 __

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TREATMENT FOR DIABETES

Have you met with a dietitian and had a nutrition program prescribed? No __ Yes __

If yes, do you limit calories? No __ Yes __ If yes, do you count carbohydrates? No __ Yes __

Do you consume alcohol? No __ Yes __

If yes, how many drinks per day? Beer ____ Wine ____ Liquor ____

Do you follow a prescribed routine exercise program?

No __ Yes __ If yes, for how long and how many times a week? _______________________________________ Type of exercise: Walking ____ Running ____ Weight training ____ Other _______________

 

 

Do you inject insulin to treat your diabetes?

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)

Do you take any oral agents to treat your diabetes?

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) __________________

Has your pharmacist or doctor told you:

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 __

Do you take any medications to treat high blood pressure? No __ Yes __

If yes, please list the medication's name(s): _________________________________________

Do you take any medications to treat high blood fats (cholesterol, triglycerides)? No __ Yes __

If yes, please list the medication's name: _________________________________________

Do you take any medications to treat diabetes complications? No __ Yes __

If yes, please list the medication's name: _________________________________________

Do you take any medications to treat any other conditions? No __ Yes __

If yes, please list all of the medications: __________________________________________ __________________________________________ __________________________________________

OTHER TOPICS

Please list any other healthcare issues that you would like to discuss:

1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________

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FOR EDUCATOR’S USE:

TOPICS THAT NEED ATTENTION:

TREATMENT PLAN:

Short-term plan: Next appointment ___________________________ Information needed from physician: _________________________________________ _________________________________________ Other:   Long-term plan:

 

Dates of Interventions		Time Spent with Patient

 

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