Please fill out this diabetes questionnaire so that DATE OF BIRTH: Please list your diabetes medications, doses and time taken: …
NAME:
Please fill out this diabetes questionnaire so that DATE OF
BIRTH:
we can better help you self manage your diabetes TODAYS DATE:
PLEASE REVIEW YOUR DIABETES SELF MANAGEMENT SKILLS
When did you find out you had diabetes? What type?
How do you feel youre managing your diabetes? Excellent_ Good_ Fair_
Poor_ Unknown_
How often do you check your blood sugars a day? None_ Once_ Twice_
Three or more_
Are most of your readings between 80 and 150? Yes__ No__ Explain:
What was your last Hemoglobin A1C or 3 month average?_____________________
Not sure__
Please list your diabetes medications, doses and time taken:
Do you ever skip or change your dose of insulin or pills? Yes__ No__
Explain:
Do you ever have low blood sugar reactions? Yes__ No__ When how often?
How do you treat them?
What low blood sugar treatment do you carry with you?
What type of meal plan do you follow?
When did you last see a Registered Dietitian?
On how many of the last 7 days did you do at least 20 minutes of physical
exercise in addition to your usual household or work activities?
0 1 2
3 4 5 6 7
What activities do you prefer?
What is your average daily tobacco use including chew?__ None__ Quit
in__ Plan
What is your average alcohol intake each week?
What is your height?_____ Weight?_____ What may be a realistic weight for
you?
Are you under any significant stresses? Yes__ No__ How are you coping?
When did you last see a Diabetes Nurse Educator?
How do you stay current on diabetes information?
DIABETES AFFECTS EVERY CELL IN YOUR BODY FROM YOUR HEAD TO YOUR TOES
When was your last dilated eye exam? By whom?
Result or treatment?
Do you see your dentist annually?
What does your blood pressure average?______________________ High__ Low__
Normal__
What is your total cholesterol?____ Triglycerides?____ Healthy HDLs?____
Lazy LDLs?___
Are you on a diet or medication to lower your cholesterol?
Are you experiencing any changes in your sexual functioning?
In the last 7 days, how many times did you examine your feet? 0 1
2 3 4 5 6 7
Who trims your toenails? Special feet/leg concerns?
WHAT IS YOUR BIGGEST CHALLENGE LIVING WITH DIABETES?
WHAT
SPECIFIC DIABETES GOAL DO YOU HAVE?
HOW CAN WE HELP?
Date: Patient Signature: Reviewed By:
DIAQUES - 12/1/98
Source:warms.vba.va.gov
