http://www.ihs.gov/medicalprograms/diabetes Why is it important to prevent type 2 diabetes in youth? The Special Diabetes Program for Indians has …
Diabetes Self-Management Training
Participant Questionnaire/Self Assessment
For Gestational Diabetes
General Information:
Name: ___________________________________________________Date
Address:
______________________________________________________Age:
What name would you like us to use?
Person filling out form:
Relationship:
Reason for not filling out form yourself:
How did you hear about this program?
Check your racial/ethnic group:
White/Caucasian African American/Black
American Indian or Alaskan Native Other__________________
Asian/Chinese/Japanese/Korean/Pacific Islander
Hispanic/Chicano/Cuban/Mexican/Puerto Rican/Latino
Social:
Do you work? Yes No Student Disabled
Type of job and hours?
Who lives with you?
How far in school did you go? ____________ How do you learn best? check
all that apply
Reading Listening Group discussion
Seeing/visual Doing Watching videos/TV
Computer Other___________________
What language do you use at
home?
____________________________________________________
Does your insurance cover all or part of:
Health care provider visit Diabetes Education
Supplies: meters strips lancets other
Note: Call insurance for this information
If you have no insurance, can you pay for these things? Yes No
Medical History:
List other health
problems__________________________________________________________
____________________________________________________________________________
_______
Have your been hospitalized for diabetes? no yes
where?______________________________
Do you have any allergies no yes
_____________________________________________________
Do you get flu shots? No Yes: Date of last flu shot:
___________________________________
Do you drink alcohol? No Yes: What kind?
__________________________________________
How much do you usually drink? Daily 2-4 times/week
Once a week Occasionally Other ______________________
Do you smoke cigarettes? Yes No
If yes, would you like information about quitting? Yes No
All Medications: Include those needing a prescription and not needing a
prescription
over-the-counter - for example aspirin, Ibuprophen
|Name of Medication |Amount |What is it for? |
| | | |
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Do you use, vitamins, herbal or home remedies, teas or supplements?
No Yes: List
|Vitamin/supplement/herbal/home remedy/teas |What do you take it for? |
| | |
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Pregnancy History
Due date:___________________
How many children are living? ____________ Were they all full term? Yes
No
How much did they weigh?
________________________________________________________________
Did you have any problems during your pregnancies? Yes No; if yes,
explain:
Nutrition:
Height: _________ Pre pregnancy weight: ________ Current weight:
___________________________
Have you ever seen a dietitian RD for diabetes? Yes No If yes, when?
Do you have a meal plan? Yes No Do you follow it? Yes No:
Why not?
How many meals do you eat daily?
How many snacks daily? __________ What kind?
Who cooks? ____________________ ______Who shops?
Do you have any religious/family customs or celebrations that involve food
or eating?
Explain:
How often do you eat out or bring home take out?
Where?
List Food allergies:
Diabetes History:
Have you ever had diabetes with a pregnancy before? Yes No; If yes,
when? ____________
Have you had diabetes education in the past? No Yes check box
below
and write date and place
Self-taught explain
how:_________________________________________________________
Physicians office:
Name:__________________________________________________________________
____________
Group classes:
_______________________________________________________________________
_____________
One-to-one meeting/s with diabetes
educator______________________________________
Do you check your blood sugar? No Yes: How often ______________ and
what do they
run?________________________________________________________________________
______________
____________________________________________________________________________
_______________
Have you been hospitalized during this pregnancy? No Yes: why?
_____________________
Do you know what the results were for any of the following tests?
|Test |Result |Date |
|Fasting blood glucose | | |
|1 hour after glucose load | | |
|2 hours after glucose load| |
|
|3 hours after glucose load| | |
Activity/Exercise:
How often are you active? None Some Often
Are you as active as you think you should be? Yes No: If no, why
not?_________________
____________________________________________________________________________
_______________
What do you do to be active or to exercise:
_________________________________________________
____________________________________________________________________________
_______________
More About You
How interested are you in learning about diabetes?
not at all
very much
Not Very
How stressed are you?
Not Very
How do you handle things that worry you?
What concerns or worries do you have for you or your baby?
What is, or will be, the hardest part of taking care of your diabetes?
My diabetes is a Disaster Burden Problem Challenge
Opportunity
What are some of the ways your family might have treated diabetes?
How does your faith or religion help you to be well?
Name 1
goal you have for your diabetes:
Do you plan to have more children? Yes No
Do you use birth control? No Yes: what kind?
____________________________________________________________________________
_______________
For Instructional Staff Only: Education Plan: Provide instruction for
specific content area/s checked on Education Plan and Record Individual
appointments Group classes Plan to address special educational
needs_______________________________________________________________________
_______________________
____________________________________________________________________________
________________________
Reviewed by:
__________________________________________________________________Date:_____
__
Reviewed by:
__________________________________________________________________Date:_____
__
Reviewed by:
__________________________________________________________________Date:_____
__
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Source:ncidc.org
