Chicago Southeast Diabetes Community Action Coalition Form A1 Reviewed and Approved
Diabetes Brief Intake Questionnaire
We would like to ask you some questions about your age, ethnic origin, education, height, weight, exercise habits, and diabetes risks This information will be used to help us decide what services and information you may need Your answers are confidential This will only take a few minutes Do you have any questions before we begin Place: __________________________ Date: _________________________
Ethnicity/Race: [_] 1 African-American [_] 2 Hispanic \Latino [_] 3 Asian [_] 4 Non-Hispanic White [_] 5Other Age years: Sex: ? 1/Female ? 2/Male Primary Language: [_] 1English [_] 2Spanish Education years: [_] 3 Other Have you ever been told by a health care provider that you have diabetes? 1 NO If NO, complete only sections A and B 2 YES If Yes, complete sections A, B and C [FOR WOMEN] Are you pregnant now? YN
First, we would like to find out whether you have access to and use certain health services A ACCESS AND PREVENTIVE CARE 1 Do you have a regular source of health care, that is, a doctor or clinic? 2 In the past year, have you seen a doctor or health care
provider for a medical checkup or physical exam? IF NO, address issues and barriers 3 Do you have health insurance, Medicaid, or Medicare? 4 In the past year, have you had a blood sugar test? 5 In the past year, has your blood pressure been taken? 6 In the past year, have you had a blood cholesterol test? 7 In the past year, have you had your teeth cleaned or checked? WOME N ONLY 8 In the past year, have you had a pap smear cervical cancer exam? 9 In the past year, have you had a breast examination or mammogram? SEDCAC \UIC Form 1 Client 12 YN YN YN YN YN YN YN YN YN Page - 1
Chicago Southeast Diabetes Community Action Coalition Form A1 B DIABETES HEALTH RISK ASSESSMENT 1 AGE SCORE: Under 45 0 points, 45-64 5pts 65 and older 9pts 2 Do you have a parent with diabetes? YES 1 point, NO 0 points 3 Do you have a grandparent with diabetes? YES 1 point, NO 0 points 4 Do you have a sibling with diabetes? YES 1 point, NO 0 points 5 Have you done any exercise for at least 3 times a week in the past month? YES 0 points, NO 5 points 6 Do you consider yourself to be overweight? YES 3 points, NO 0 points
Pts 5 1 1 1 5 3 5 9
7a What is your weight? Weight |___|___|___| Lbs 7b
What is your height? Height|___||___|___| feet/inches BMI________ [SEE BMI CHART] BELOW/EQUAL/ABOVE? [SEE CONVERSION CHARTS] BMI over 25 5 points 8 Did you weigh more than 9 pounds 41 kg when you were born? YES 1 point , NO 0 points 9 [WOMEN] Have you had a baby weighing more than nine pounds at birth? YES 6 points, NO 0 points 10 [WOMEN] Did you ever have diabetes during a pregnancy? YES 1 point, NO 0 points 11 Have you been told by a health provider that you have high blood pressure or hypertension? YES 1 point, NO 0 points 12 Have you been told that you have high cholesterol levels? YES 1 point, NO 0 points 13 Have you been told by a health care provider that you have heart disease? YES 1 point, NO 0 points 14 Have you been told by a health care provider that your blood sugar is high or elevated, even if only intermittently? YES 1 point, NO 0 points RISK SCORE: [If greater than 10 points, you are at high risk of diabetes] Total Recommendations : ? Blood Glucose Testing ? Brief Risk Reduction Counseling WAAVE ? Referral for Testing ? Health Education specify ? Referral to Healthcare Services ? Exercise Program PLAN: SEDCAC \UIC Form 1 Client
1
6 1 1 1
1
1
Page - 2
Chicago Southeast Diabetes Community Action Coalition Form A1
C DIABETES CARE ASSESSMENT 1 Have you had diabetes for more than 1 year? |____|_____| IF YES, How many years?
Indicator YN ____ |___| |___| |___| Y N DK 012 34 Y N DK YN YN YN YN YN |___| YN
2 In the past year, how many times were you seen by a health care provider for diabetes? 3 In the past year, how many times did you receive diabetes education? No of classes 4 In the past year, how many times did you receive nutrition or meal planning education from a dietitian? 5 How many times a day do you check your blood glucose? 6 Have you heard of Glycosylated Hemoglobin or Hemoglobin A1C? 7 In the past year, how many times was your Glycosylated Hemoglobin A1c checked? 8 Do you have high blood pressure? 9 If you have high blood pressure, are you receiving treatment? 10 In the past year, have you had a blood cholesterol test? 11 IF YES, Have you been diagnosed with high cholesterol? 12 If you have high cholesterol, are you receiving treatment? 13 In the past year, have you had a dilated eye exam? 14 In the past year, how many times were your feet examined by a health care provider? 15 In the past year, have you
had a flu shot?
PLAN : ? Do IEPIndividual Education Plan ? Diabetes Education ? Dietitian ? Eye Care ? Foot Care ? Dental Care ? Heart Care ? Other:
SEDCAC \UIC Form 1 Client
Page - 3
Source:managedcaremag.com
