Diabetes Self-Management Education Services Initial Assessment Does consumer belong to and/or attend any diabetes or visual impairment support groups? …
|Division for Blind Services
Consumer Services Report:
Diabetes Self-Management Education Services - Initial Assessment | |
|1 Consumer Information |
|Consumer Name: |
|Consumer Address: |
|Counselor Name: |Caseload Number: |
|Referral Date: |Assessment Date: |Purchase Order Number: |
|2 Consumer Demographics |
|Age: |Sex enter X to |Marital status enter X to select: |Number in |
| |select: |Married Divorced Single Widow|household: |
| |F M | | |
|Occupation: |Hours worked per week: |
|Primary insurance: |
|Secondary insurance:
|
|Can consumer meet diabetes-related expenses eg, |Yes No |
|nutritional needs, medications, test strips? enter X to | |
|select | |
|If no, enter explanation and/or comments: |
|3 Support System |
|Primary support person: |Telephone number: |
| | |
|Does consumer have sighted assistance available when needed? enter X to select Yes |
|No |
|Does consumer currently receive home health services? enter X to select Yes No |
|Does consumer belong to and/or attend any diabetes or visual impairment support |
|groups? enter X to select Yes No |
|4 Diabetes History |
|enter X to select Type
1 Type 2 |Duration: |
|Other: | |
|Previous diabetes training: |
|How does consumer keep their diabetes information updated? |
|5 History of Complications |
|Enter X for all that apply: |
| Foot problems | Retinopathy | Neuropathy | Renal problems |
| Cardiovascular | Other complications |
|Describe other complications: |
|6 Risk Factors |
|Enter X for all that apply: |
| Family history of | Over age 45 | Using | Smoking |
|diabetes | |Alcohol | |
| High blood pressure | Obesity |Height:
|Weight: |
|Race/ethnicity describe: |
|Other risk factors describe: |
|7 Present Medical Conditions |
|Condition: |Treatment and/or medications: |
|Condition: |Treatment and/or medications: |
|Condition: |Treatment and/or medications: |
|Condition: |Treatment and/or medications: |
|Condition: |Treatment and/or medications: |
|Does consumer have any allergies |List allergies: |
|enter X to select? | |
|Yes No | |
|Comments: |
|8 Diabetes-Related Health Care Services |
|Consumers primary care
physician:|Address: |Telephone: |
| | | |
|Provide last exam dates: |Physical exam: |Eye exam: |
| |Dental exam: |Foot exam: |
|Has consumer been to the emergency room in the past 12 |Yes No |
|months enter X to select? | |
|If yes, explain number of times, reason for visit, etc: |
|Has consumer been hospitalized in the past 12 months enter |Yes No |
|X to select? | |
|If yes, explain number of times, reason for hospitalization, etc: |
|9 Insulin |
|Select insulin brand consumer uses:|Dose: |Time administered: |
|Lilly | | | |
|Novo | | |
|
|Aventis | | | |
|Other | | | |
|How is insulin measured? |
|Can consumer correctly demonstrate/verbalize drawing up |Yes No |
|insulin enter X to select? | |
|How is insulin administered? |
|Does consumer utilize proper site rotation enter X to |Yes No |
|select? | |
|What injection sites are used enter X to select all that apply? |
|Abdomen Thigh Arm Buttock Other specify : |
|Does consumer experience any injection site problems enter |Yes No |
|X to select? | |
|If yes, specify: |
|What syringe size does consumer use?
|
|Does the consumer re-use his or her syringes enter X to |Yes No |
|select? | |
|Does consumer utilize appropriate syringe disposal |Yes No |
|procedures enter X to select? | |
|Does consumer change his or her diabetes medication dosage,|Yes No |
|frequency, etc only with direction from his or her | |
|physician enter X to select? | |
|10 Resource Testing Supplies |
|Name of consumers blood glucose meter: |
|Can consumer verbalize/demonstrate competency in use of the |Yes No |
|blood glucose meter enter X to select? | |
|Who performs the test? |
|Can consumer read the systems display enter X to select? |Yes No |
|Test times before/after meals:
|
|Frequency of testing times per day/week/month: |
|What is the consumers blood sugar goal? |
|Does consumer test urine ketones enter X to select? |Yes No |
|Does consumer have updated supplies for ketone testing |Yes No |
|enter X to select? | |
|11 Nutrition |
|Who prepares and/or cooks the consumers meals? |
|How many meals per week does consumer eat away from home enter X to select? |
|None 1-3 4-7 8 or more |
|Describe any food preferences, food dislikes, special diet or eating habits eg, |
|allergies, intolerances, religious or cultural considerations, etc: |
|Sample intake for breakfast: |
|Sample intake for lunch: |
|Sample intake
for dinner: |
|Sample intake for snacks: |
|12 Meals |
|Enter time when consumer eats: |Breakfast: |Lunch: |
| |Dinner: |Snack: |
|Check which eating times consumer skips, if any enter X |Meals |Snacks |
|to select | | |
|13 Exercise Habits |
|Does consumer have any physical problems that limit exercise enter |Yes |No |
|X to select? | | |
|Does consumer participate in regular exercise enter X to select? |Yes |No |
|Type of exercise: |
|Frequency of exercise: |Duration of exercise: |
|14 Employment Aspects of Diabetes
|
|In the last 6 months, has the consumer missed work due to |N/A |Yes |No |
|diabetes enter X to select? | | | |
|Explain: |
|In the last 6 months, has the consumer missed school due to |N/A |Yes |No |
|diabetes enter X to select? | | | |
|Explain: |
|Has consumer experienced difficulty performing job duties |N/A |Yes |No |
|enter X to select? | | | |
|Explain: |
|Does consumer need a flexible work schedule enter X to |N/A |Yes |No |
|select? | | | |
|Does consumer need frequent breaks enter X to select? |N/A |Yes |No |
|Does consumer need meal accommodations enter X to |N/A |Yes |No |
|select?
| | | |
|Does consumer understand diabetes-related impact on |N/A |Yes |No |
|employment enter X to select? | | | |
|15 Learning Barrier Assessment |
|Learning barriers have been identified enter X to select? |Yes |No |
|Visual barriers? |Yes |No |Auditory barriers? |Yes |No |
|Decreased hand sensation? |Yes |No |Lack of |Yes |No |
| | | |transportation? | | |
|Literacy barriers? |Yes |No |Highest level of education: |
|Primary Language: |English |Spanish |Other Specify: |
|Are there barriers to consumers to make change enter X to |Yes |No |
|select? | | |
|Explain: |
|Financial barriers enter X to select? |Yes |No
|
|Explain: |
|Does consumer experience difficulty with independent living skills|Yes |No |
|due to diabetes enter X to select? | | |
|Explain: |
|16 Consumers Learning Style |
|Consumers best learning style enter X for all that apply: |
|Individualized | |Lecture: | |
|instruction: | | | |
|Group training: | |Hands-on demonstration: | |
|17 Recommendation and Comments |
|Education services recommended enter X to |Individual |Group |Both |None |
|select: | | | | |
|Comments: |
|Start time of visit: |End time of
visit: |
|Date of evaluation: |Total hours for evaluation: |
|Signature |
|Provider: |Date: |
|X | |
