4. Is there anyone who will help you in your diabetes care? Yes No If yes, who 6. Do you use pills for your diabetes medication? …
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Name: UIN:
Diabetes History Form
General Information
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Date:
Education Major Expected Graduation Marital Status Single Married Other How many people live in your household? Is there anyone who will help you in your diabetes care? Yes No If yes, who Do you work outside of taking classes? Yes No Where Hours/week Diabetes provider at home Phone Type 2 Fair Gestational Poor Unknown
Diabetes History
How long have you had diabetes? What type? Type 1 List any family members with diabetes How would you rate your understanding of diabetes? Good What areas of diabetes would you like to learn more about? Diet Stress Blood testing Low blood sugar Exercise Sick days Complications High blood sugar 5 How do you learn best? Written material Verbal discussion 6 What is your goal for this session? Learn more about diabetes Better blood sugar control
Insulin pumps Pills for diabetes Pregnancy and diabetes Hands on Help with meal planning Weight management
Nutrition
1 Has your weight changed in the last 3 months? Yes No I have Gained Lost lbs Was this weight change intentional? Yes No 2 How many times do you eat per day? Meals Snacks 3 How often do
you eat/drink the following? per week Fruits Vegetables Sweets Fast Food Milk fat free, Juices Cheese Alcohol Water 1, 2, whole 4 How often per week do you eat away from home? Where 5 How is your food prepared? Fried Baked Broiled Grilled 6 How would you describe your portions? Small Average Large 7 Any special diet needs or practices? 8 Have you ever been told you have High cholesterol High triglycerides High blood pressure 9 What diet plan do you typically follow? Carb counting Calories a day Other 10 How is your insulin dosage calculated? N/A Carbs to units insulin type Fixed dose per meal type Adjustable dose dependent on blood glucose 11 Complete the food history table below including amount and how typically prepared
Breakfast
Lunch
Dinner
Snack
Snack
Snack
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Name:
Diabetes History Form page 2 Medication 1 If you take insulin: if no skip to 6
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UIN: Date:
Do you use? A syringe Insulin pen Insulin pump Insulin inhaler What injection sites are used? Where do you keep your insulin? Do you reuse your syringes? Yes No How many times before disposal? How/where do you dispose of your syringes? Do you use pills for your diabetes medication?
Yes No If yes, list amount and frequency below:
Monitoring
1 Do you test your urine: For sugar? 2 Do you test your blood sugar? 3 Do you keep a record of you results? Yes Yes Yes No No No For ketones? How often? Yes No How often Typical results
Exercise
1 Do you exercise regularly? Yes No What type? How often? For how long? 2 List any problems you have with exercise: Complications 1 If you have ever had a low blood sugar reaction? How did you feel? How did you treat it? How often has this occurred? 2 Do you carry a source of sugar with you? Yes No 3 Have you ever had to be given glucagons? Yes No 4 If you have ever had High blood sugar: How did you feel? How did you treat it? How often has this occurred? 5 What is your daily blood sugar normal range? 6 Are you aware of the long term complications of Diabetes? Yes No 7 Do you have any of the following? Eye problems Heart problems Kidney problems Numbness/pain Sexual problems Dental problems Please Explain Medical History Eye exam? Dental exam? 1 When was your last: Physical? 2 Do you smoke? Yes No If yes, how much? For how many years? 3 Do you drink alcohol? Yes No If yes, how much? 4 Have you ever been hospitalized with diabetes?
Yes No Number of times 5 Have you been in the emergency department because of your diabetes? Yes No How many times 6 Do you wear a medical identification bracelet or necklace? Yes No 7 Have you ever had a Pneumonia vaccination? Yes No When? 8 Have you received a Flu shot within the year? Yes No
Other
Please list any other information that you feel would be important for your provider to know that would assist them in treating you:
Patients Signature Providers Signature
Date Date
11/22/06:bah
Source:mckinley.uiuc.edu
