You may leave blank any areas of which you are uncertain and the Diabetes Educator will about your health and diabetes? Areas of interest/concern for …
DIABETES MANAGEMENT 5008 SOUTHPOINT PARKWAY FREDERICKSBURG, VA 22407
PHONE: FAX:
540-741-2210 540-741-2211 INSTRUCTIONS
Please provide the information requested in PART I and III; this information will help us serve you better You may leave blank any areas of which you are uncertain and the Diabetes Educator will review the information with you during your session
PART I - TO BE COMPLETED BY PATIENT
DEMOGRAPHIC INFORMATION
NAME ADDRESS STREET CURRENT DATE
HOME PHONE
CITY, STATE, ZIP
OCCUPATION
RACE
WORK PHONE
SOCIAL SECURITY
DATE OF BIRTH
MARITAL STATUS S M W D
NAME OF REFERRING PHYSICIAN
NAME OF FAMILY PHYSICIAN
GENERAL MEDICAL INFORMATION
IF YOU ARE ALLERGIC TO ANY MEDICATIONS, PLEASE LIST THEM IF YOU HAVE OTHER ALLERGIES, PLEASE LIST THEM
PLEASE LIST ANY CHRONIC ILLNESS AND DATE OF DIAGNOSIS
PLEASE LIST DATE/TYPE OF PAST SURGERIES
PRESCRIBED MEDICATIONS BY MD
OVER THE COUNTER MEDICATIONS
HIGH BLOOD PRESSURE
YES
NO
PART II - TO BE COMPLETED BY DIABETES EDUCATOR
HEIGHT PAST HISTORY OF GESTATIONAL DIABETES: YES NO GRAVIDA/PARA ________/_____ WEIGHT DELIVERY GOALS: NATURAL BIRTH MEDICATION POST PARTUM GOALS: BREASTFEED BOTTLEFEED COMBINATION PRE-PREGNANCY WT
CHILD 1 BIRTH WT _________ C-SECTION VAGINAL COMMENTS: EDC CHILD 2 BIRTH WT _________ C-SECTION VAGINAL SINGLE BIRTH MULTIPLE BIRTH CHILD 3 BIRTH WT _________ C-SECTION VAGINAL
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Outpt Diab Mgmt Record Pregnant Patient
FR-1184A-DIABMGMT 8/2005 Page 1 of 2
PATIENT IDENTIFICATION 1 1/4 X 3
Diabetes History Type Type 1 Gestational Type 2 Other Treatment Name of insulin or oral drug Dose Side Effects Diet/Exercise Oral pills Insulin Monitor Blood Sugar? Which meter? How often/time of day? Usual readings Do you record results? Yes No Yes No Do you have family his 
tory of diabetes? Time lost from work or school in the past year due to diabetes? Mother Father Sibling Other Yes No How many days? Pain Assessment Do you have any chronic pain? If yes, where located? Duration of pain? Any treatment? Yes No How would you rate the pain? 1 2 3 4 5 6 7 8 9 10 10 is the worst and 1 is the least Describe: Physical Activity Habits Any restrictions for activity by MD: Regular exercise program: Type and Duration: Yes No Yes No Education History Level of Education Problems with learning? If yes, describe Grade School High School College Yes No Have you had any diabetes education If yes,
when and where? Did friend/family participate? before? Yes No Yes No Note to Diabetes Educator: Document previous education on Diabetes Management Protocol Social History Do you smoke? Yes No Do you drink alcohol? Yes No Do you have an eating disorder? Yes No If yes, is your physician aware? Yes No Do you use community resources? example -Health Department, If yes, which ones? Rappahannock Community Services Board Yes No How many people live in your home? What are their relationships to you? Hygiene Patterns Do you see a dentist once per year? Yes No Do you see an eye doctor once a year? Yes No Do you practice some form of contraception when not pregnant? Yes No Health Belief/Goals/Attitudes Feelings about your health and diabetes? Areas of interest/concern for education session? Signature of Diabetes Educator Date
Date Individual Class Group Class Part III - To Be Completed By Patient Length of time since diagnosis If recently, signs and symptoms
RN3890 RN3890
Outpt Diab Mgmt Record Pregnant Patient
FR-1184A-DIABMGMT 8/2005 Page 2 of 2
PATIENT IDENTIFICATION 1 1/4 X 3
Source:medicorp.org
