INDIVIDUALIZED INITIAL DIABETES ASSESSMENT Copyright 2012 Provena Mercy Medical Center Center for Diabetic Wellness EDUCATOR S INITIALS:
|
|
- Tracy Stevens
- 5 years ago
- Views:
Transcription
1 PERSONAL HISTORY DIABETES INFORMATION CLINICAL DATA Name: Phone: (H) (C) (W) Primary Provider Name: Occ (O) (F) Marital Status: Single Married Divorced Widowed Cohabitating Occupation: Hours per week: Work Shift: 1 st 2 nd 3 rd Work Schedule: MEDICAL HISTORY / FAMILY HISTORY Type of Diabetes: New Onset Uncontrolled Type 1 Type 2 Pre-Diabetes Treatment: Diet-controlled Oral medication Combination therapy Insulin Injections Insulin Pump Diagnosed for how long: Have you had prior diabetes education: No Yes If yes, when? Do you have specific educational needs? No Glycemic Date: FBG (<100 mg/dl) Impaired FG ( mg/dl) Have you been diagnosed with any of the following or do you have a concern? (Please check all that apply) Diagnosed Concern Diagnosed Concern Diagnosed Concern Amputation Heart Disease Liver Disease Arthritis High Blood Pressure Peridontal Disease Asthma or COPD High Cholesterol PVD Bi Polar High Lipids Retinopathy Cancer High Triglycerides Sexual Dysfunction Cataracts Kidney Disease Seizures Glaucoma Chronic Kidney Disease Sleep Apnea CAD/CVD Mental Health Stroke TIA Dental or mouth MI Substance Abuse Depression Neuropathy Thyroid Digestion Problems Numbness/tingling/ Tuberculosis Eating Disorder burning in feet or hands Eye/Vision Problems Erectile Dysfunction Obesity Foot problems Gastroporesis Morbid Obesity Skin conditions Pancreatitis Yes Have you had prior nutritional counseling: No Yes If yes, when? Lipids Date: Total Cholesterol (<200 mg/dl) LDL (<100 mg/dl) HDL (>40-60) Triglycerides (<150 mg/dl) Height Measurement PRE POST A1C (<7%) B/P (<130/80mm/hg) Weight BMI ( ) 1325 N. Highland Avenue Aurora, Illinois (630) / Phone (630) / Fax Source: American Diabetes Association (ADA), Please list any other medical problems here: Please list any surgeries: Do you have family history of diabetes? Yes No Father Mother Siblings Grandparents Aunts/Uncles 1
2 What pharmacy do you use: Location: Phone: Do you have any food, drug or environmental allergies? No Yes Do you take aspirin? No Yes Please copy information off pill bottles. List diabetes medication first. Name Dose How often Comments Patient did not bring medications today. Instructed to bring to next appointment. Please list names of Complementary and Alternative Therapies: None INSULIN: Skip this section if client does not take insulin Type Units Time of Day How do you take your insulin? syringe insulin pen insulin pump Who fills your insulin syringe? self spouse parent partner Who gives you your insulin injection? self spouse parent partner What injection sites do you use? stomach thighs arms other Do you alternate injection sites? No Yes Where do you keep your insulin? refrigerator bathroom car other Where do you dispose of your syringes? garbage sharps container other Additional Comments: Health Beliefs / Attitudes / Learning Needs How important is your health to you? very important somewhat important not very important How would you describe your general health? Excellent Very Good Good Fair Poor Who makes decisions about your health? self spouse parent partner doctor other How do you feel about having diabetes? angry sad frightened anxious guilty frustrated hopeless lonely ashamed defeated I don t have diabetes other How content do you feel about your life? I feel confident that I know how to control my diabetes I learn best by: lecture discussion demonstration print material audio/visual computers/online role playing games Are you able to read or write: No Yes What level of schooling have you completed: 2
3 Place a check mark in the appropriate box and answer the questions to the right of the yes / no boxes if applicable. Monitoring Yes No Do you monitor your blood glucose (sugar) regularly? Name of monitor Have you experienced low blood glucose readings recently or frequently? (<70 mg/dl or symptoms) Do you need assistance when hypoglycemic? Have you experienced high blood glucose readings recently or frequently? (>250 mg/dl or symptoms) Have you ever been hospitalized due to diabetes complications? (Ketoacidosis, HHS) Do you perform daily foot inspections? Do you get a complete foot exam annually? Do you get your eyes dilated annually? Do you get your teeth examined every 6 months? Physical Activity YES NO If no, please explain: If yes, please elaborate: Frequency: once daily twice daily Other Time of day: fasting before meals after meals bedtime Frequency: daily weekly monthly rarely Time of day: morning afternoon evening overnight after exercise skip a meal Frequency: daily weekly monthly rarely Time of day: morning afternoon evening overnight Are you currently exercising? (4 or more times a week) Type of exercise Times per week Length of time Do you have any restrictions? Are you interested in becoming more physically active? Do you have a sedentary lifestyle/job? Cultural / Financial YES NO Do you have any cultural or religious practices involving foods, eating habits or fasting? Do you have any financial concerns or lack of health insurance? Psychosocial YES NO Do you drink alcohol? Do you use tobacco? Former tobacco user Duration: Quit date: Have you had a significant change in life events (marriage, divorce, illness, death of family member, new home or change in employment) in the last 12 months Please rate stress in your life on a 0 (no stress) to 10 (high stress) scale: If no, please explain: Please explain: Please explain: If yes, check type and include amount per week: Beer Wine Liquor Amt/Wk If yes, indicate type and amount per day: Cigarettes Pipe Cigar # Packs/day #/day #/day Please describe: Mark source(s) of your stress? Work Unemployment Family Health Finances other What do you do to handle stress in your life? 3
4 Family Support and Support Systems YES NO Do you have a significant other, family member, friend or relative with whom you can discuss personal problems and concerns and who could support you in managing your diabetes? Do you have a support person that will be attending your appointments with you? Relationship: Name: Relationship: Who helps you with your diabetes care at home? spouse partner parent daughter/son friend other no one Because diabetes self-care management can take a toll on your emotions and stress level, we ask all our clients the following: During the past week, have you been bothered by feeling down, depressed or hopeless? No Yes During the past week, have you had little interest or pleasure in doing things? CESD Score No Yes Nutrition YES NO Do you currently follow any special diet? Do you have any dietary restrictions? Do you take vitamins, minerals, herbs or any other food/nutritional supplement? Do you do the shopping and/or cooking? Do you eat meals away from home? Do you often eat high fat foods such as pizza, sausage, bacon, gravy, chips, fried foods, butter, cheese, salad dressings, sour cream? Do you often eat high sodium foods such as frozen meals, canned soups or vegetables, instant soups, deli meats, salt? Do you often eat high sugar foods such as desserts, cookies, ice cream, pastry, candy, or sweet breads? If yes, check type: Low Cholesterol Low Sodium calorie counting Carb Counting Low Fat Exchange Label Reading Low Protein Other If yes, please list: If No, indicate who does it: Shopping Cooking How many people in your household? If yes, check which one(s) and number of times per week: Breakfast Lunch Dinner times/wk times/wk times/wk Do you often drink beverages high in sugar such as energy drinks, fruit juice, soda, sports drinks, yogurt drinks, or flavored milks? How many times a day do you eat? What are some of the foods you eat the most? What are some of the foods you avoid? (Please explain) Indicate your usual schedule (Write time of day for each item listed.) Time you get up Time you eat breakfast Time you begin work / school Time you eat lunch Time you get off work Time you eat dinner Bedtime Notes: 4
5 For Educator s Use Only EDUCATOR S ASSESSMENT Barriers to Learning None Language (LEP) Inability to read Visual Physical disabilities Work Schedule Hearing Child care Transportation Comprehension Emotional Problems Financial Memory Recall Special Needs Other: Age Unique Patient Needs: Education Readiness Pre-contemplation (Aware of condition) Contemplation (Thinking about making changes) Preparation Stage (Makes plans for change) Action Stage (Takes active steps towards change) Education Plan Comprehensive DSME Group Individual English Spanish Morning Evening DSME (Select Topic) Disease Process Monitoring Nutrition Medications Problem Solving Acute complications Physical Activity Long Term Complications Psychosocial Adjustment Insulin Instruction only Modified Plan: Date & Plan: Date & Plan: Referrals / Consults Registered Dietitian Ophthalmology (self pay) Smoking cessation Support Group Optometry (self pay) Financial Counselor Endocrine (self pay) Community Resources: MANAGEMENT PLAN Monitoring Plan Goals and Outcomes Source: American Diabetes Association, 2010 & American Association of Clinical Endocrinologist, 2010 Frequency: Fasting Pre meals:b L D 1 hr PP: B L D Target Ranges: mg/dl <110 mg/dl Other mg/dl <110 mg/dl Other Intermediate Outcomes: Performs daily SMBG within target ranges / record results Follows meal plan as recommended Takes medications as prescribed Complete DSME Program 2 hr PP: B L D <180 mg/dl <140 mg/dl Other Post -Intermediate Outcome: A1C less than 7% A1C less than 6.5% Bedtime Bedtime: mg/dl ADDENDUM: Print Name (Conducted By) Signature Title Date Print Name (Reviewed By) Signature Title Date 5
DIABETES SELF MANAGEMENT EDUCATION / NUTRITION COUNSELING INITIAL ASSESSMENT. NAME Today s Date
NAME Today s Date DATE OF BIRTH CONTACT INFORMATION: Home Number Cell phone number Work Number Okay to call at work? No Yes Answering machine No Yes Ok to leave message Your own personal Email Address
More information**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!
Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.
More information**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!
Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.
More informationThe Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
More informationJohnson City Internal Medicine 301 Med Tech Parkway, Suite 240, Johnson City, TN (423)
IDX# Johnson City Internal Medicine 301 Med Tech Parkway, Suite 240, Johnson City, TN 37604 (423)794-5823 SoFHA Diabetes Clinic Assessment Instructions: Please complete and bring to your appointment with
More informationParticipant Self-Assessment of Diabetes Management
Participant Self-Assessment of Diabetes Management Name: Date: Date of Birth: Age: Gender: F M Ethnic Background: White/Caucasian Black/African American Hispanic Native American-Alaska Asian/Pacific Islander
More informationLifestyle & Pre-diabetes Questionnaire
Please complete this questionnaire. The time you take to provide this information will help your health care team work better for you. General, Medical and Health Information Date: Name: Age: Race: Current
More informationPatient Information. First Name Middle Last Preferred Name. Street Address City State Postal Code
Ms. Patient Information First Name Middle Last Preferred Name Street Address City State Postal Code Work Phone ( ) Home Phone ( ) Cell Phone ( ) Email Preferred Contact Email Cell Home Work Emergency Contact
More informationEmily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA (610)
Emily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA 19087 (610) 574 0079 emilymurray1@gmail.com Dietitian History Questionnaire and Assessment General Information:
More informationDate of Birth. Black/African American. What is your occupation? Retired? Yes No
Health Risk Assessment Today s Date: Name Date of Birth GENERAL INFORMATION What is your race? American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Asian, Chinese, Japanese, Korean
More informationMedicare Annual Wellness Visit Questionnaire
Medicare Annual Wellness Visit Questionnaire Answering these questions will help you and your health care provider develop a personalized prevention plan to help you stay healthy and plan for future health
More informationNutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD
Nutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD First Name Last Name Please indicate your preferred method of contact: home cell email text other: Sex: Male Female Birth date: / / Age:
More informationLegacy Weight and Diabetes Institute New Patient Information
Legacy Weight and Diabetes Institute New Patient Information Answering these questions will help your providers understand your health and how best to treat you. If you need help filling out this form,
More informationPrimary Medical Associates. Patient Information Sheet:" Patient Name Date of Birth " Mailing Address: " City State Zip " Phone# (H) SS# "
1 of 10 Patient Information Sheet: Patient Name Date of Birth Mailing Address: City State Zip Phone# (H) SS# Patient s Employer Phone# ==================================================================
More informationHealthy Hearts, Healthy Lives Health and Wellness Journal
Healthy Hearts, Healthy Lives Health and Wellness Journal Healthy Hearts, Healthy Lives You Are in Charge You can prevent and control heart disease by making some lifestyle changes. Keeping your journal
More informationHealth Risk Assessment
Health Risk Assessment Today s Date: Name Date of Birth GENERAL INFORMATION What is your race? American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Asian, Chinese, Black/African
More informationNutrition Assessment
Today s Date: Basic Information Name: Age: Gender: Date of Birth: Phone Number: Email Address: I prefer to be contacted via (please circle): phone email Reason for your visit: Occupation: Do you have children?
More informationBEHAVIORAL RISK FACTORS
EXAMPLES OF QUESTIONS IN AN HRA BEHAVIORAL RISK FACTORS PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do you usually
More informationLipid Clinic Name DOB / / Primary Care MD Cardiologist Endocrinologist
Lipid Clinic Name DOB / / Date Primary Care MD Cardiologist Endocrinologist Allergies to medications (please include reaction) Marital Status (Please circle) Educational Level (Please circle highest level)
More informationWelcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals!
Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals! What to expect.. Your first appointment with our center will last approximately one hour, possibly
More informationIf you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
More informationLiving Well with Diabetes. Meeting 12. Welcome!
12-1 Welcome! Welcome back and congratulations! Today is a time to celebrate all of your accomplishments. For the past few months we have learned a great deal about managing diabetes. Today, we will talk
More informationHealth & Wellness Assessment. Name Date of Birth. List the names of any doctors, medical providers, nurses, or medical suppliers that you have:
1 Health & Wellness Assessment Name Date of Birth List the names of any doctors, medical providers, nurses, or medical suppliers that you have: Name Phone Services You Receive General Health In general,
More informationNebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
More informationBariatric Patient Nutrition & Lifestyle History. What Bariatric procedure are you considering? Bypass (RNY) Sleeve
Bariatric Patient Nutrition & Lifestyle History Name Patient ID # Date 5% goal weight What Bariatric procedure are you considering? Bypass (RNY) Sleeve Weight History Current weight: lbs. What has been
More informationDiabetes Self-Care Assessment Date:
Diabetes Self-Care Assessment Date: Personal Information: Name: Are you: Married Single Widowed Other Do you live: Alone with Spouse with Others Do you have any condition that affects your ability to take
More informationInitial Medical Questionnaire Please complete this questionnaire and bring it with you to your first appointment.
Center for Weight Management and Bariatric Surgery Initial Medical Questionnaire Please complete this questionnaire and bring it with you to your first appointment. Name: Street City State Zip Code Home
More informationDiabetes and Heart Disease Awareness Molina Healthy Living with Diabetes sm and Heart Healthy Living sm
Diabetes and Heart Disease Awareness Molina Healthy Living with Diabetes sm and Heart Healthy Living sm Molina Healthcare of Michigan Summer 2013 Living a Healthy Life with Diabetes Many people avoid the
More informationClient Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
More informationStaying Healthy with Diabetes
Staying Healthy with Diabetes Note to the Health Care Provider: Topics in this handout are discussed in Chapters 6 and 13 of the American Dietetic Association Guide to Diabetes Medical Nutrition Therapy
More informationSingle Married Divorced Widowed Male Female
Annual Physical Form General Information Name Birth Date Phone Email Address Street Address City State Zip Marital Status Gender Single Married Divorced Widowed Male Female Employment Information Position
More informationNutrition Solutions, LLC Cancellation Policies
, LLC Cancellation Policies Thank you for choosing. Our mission is to educate, inspire and guide you to better health and wellness with balanced nutrition. Due to high demand for appointments we ve had
More informationHealth History. Date. Address. City State Zip. Age Height Weight BMI. Date of birth Male Female. . Are you currently a patient at OHSU?
OHSU BARIATRIC SERVICES Health History Please fill out this form completely and email or fax to the contact information at the bottom of this form. We will contact you to set up an appointment. Date Name
More informationLeslie Brocchini, MD Wellness Medicine
New Patient Questionnaire Name: Main complaints today: 1. Most important problem: Leslie Brocchini, MD Date: a. What treatments have been recommended for this so far? b. Success obtained with those treatments?
More informationSample Well-being Assessment
Sample Well-being Assessment This assessment addresses the following eight categories, as well as the importance, readiness, and confidence in each category: Energy Stress Management Life Balance Weight
More informationName: DOB: Today s Date: Pre-diabetes Type 2 diabetes Gestational diabetes. Type 1 diabetes/latent Autoimmune Diabetes of Adults (LADA)
NEW PATIENT DIABETES HISTORY FORM Name: DOB: Today s Date: What type of diabetes do you have? Please circle: Pre-diabetes Type 2 diabetes Gestational diabetes Type 1 diabetes/latent Autoimmune Diabetes
More informationAndrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
Background Information Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ 08816. aberezrd@njpedsrd.com Adult Patient Nutrition Assessment/Diet History Form
More informationSUPPORT STAFF TRAINING TOOLS MAINTAINING HEALTH. THE HEALTHY MENU (Including the MyPlate Information)
SUPPORT STAFF TRAINING TOOLS MAINTAINING HEALTH THE HEALTHY MENU (Including the MyPlate Information) Training Program Specialists, LLC 9864 E. Grand River, Suite 110-320 Brighton, Michigan 48116 Phone:
More informationOn at am/pm for an individual appointment a group appointment at the following location:.
501 New Karner Road, Suite 1A Albany, NY 12205 (518) 452-1337 Option 1 www.capcare.com Hello and Welcome to the CapitalCare Medical Group Nutrition and Diabetes Program. Living with diabetes requires dedicated
More informationPrediabetes 101. What is it and what can I do about it? Intermountainhealthcare.org/diabetes
Prediabetes 101 What is it and what can I do about it? Patient Education Intermountainhealthcare.org/diabetes What do you already know about prediabetes? Fact or Fiction? There are often no symptoms of
More informationInitial Client Questionnaire
Initial Client Questionnaire First Name: Middle Initial: Last Name: How did you hear about my services: Medical History Pregnant: Yes No Nursing: Yes No When was your last physical exam? What are your
More informationHEALTH HISTORY QUESTIONNAIRE
HEALTH HISTORY QUESTIONNAIRE PATIENT INFORMATION Name: (First MI Last) Date of Birth: (Month/Day/Year) Race/Ethnicity: DEMOGRAPHIC INFORMATION Age: Gender: Male Female White Black/African American Biracial/Multiracial
More informationLifestyle and Metabolic Medicine
Lifestyle and Metabolic Medicine Demographics First Name Date of Birth / / Mailing Address City, State, Zip code Preferred phone Secondary phone Email address Referred by Primary Care Physician New Patient
More informationNew You Weight Management Program
New You Weight Management Program Initial Evaluation Form (All questions MUST be answered to be considered for the program. Patients are NOT chosen on a first-come, first- served basis. The information
More informationName: DOB: Today s Date: Pre-diabetes Type 2 diabetes Gestational diabetes. Type 1 diabetes/latent Autoimmune Diabetes of Adults (LADA)
INTERNAL REFERRAL DIABETES HISTORY FORM Name: DOB: Today s Date: What type of diabetes do you have? Please circle: Pre-diabetes Type 2 diabetes Gestational diabetes Type 1 diabetes/latent Autoimmune Diabetes
More informationPreferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
More informationNutrition Initial Assessment
Nutrition Initial Assessment Client Name: Referring Physician: Home Phone: Home Address: Date: Email: What are the goals that you are trying to achieve with your initial appointment? Past Medical History:
More informationYOU ARE WHAT YOU EAT. 2. Do you eat more packaged (frozen or canned) fruits & vegetables than fresh?
YOU ARE WHAT YOU EAT 1. Do you shop for food less frequently than every four days? 2. Do you eat more packaged (frozen or canned) fruits & vegetables than fresh? 3. Do you eat more cooked vegetables than
More informationDiabetes Education 1/23/2014
Diabetes Education JESSICA GOECKING MS RD LD OUTPATIENT DIETITIAN UT HEALTH NORTHEAST TYLER, TEXAS What is Diabetes? Diabetes is a group of diseases characterized by high levels of blood glucose (blood
More informationPatient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire
More informationSample Health Risk Assessment
Sample Health Risk Assessment The HRA questions outlined below are provided as examples. They represent one HRA model. Use of this model is not a requirement for the Medicare Annual Wellness Visit HRA,
More informationNutrition Tips to Manage Your Diabetes
PATIENT EDUCATION patienteducation.osumc.edu As part of your diabetes treatment plan, it is important to eat healthy, stay active and maintain a healthy body weight. This can help keep your blood sugar
More informationPATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
More informationADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
More informationDenise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
More informationNutrition History and Questionnaire
Nutrition History and Questionnaire Florida Surgical Weight Loss Center Last Name: First Name: Address: e-mail address: DOB: Occupation: Highest Education Level Completed: Grade School High School College
More informationLIFE STYLE ASSESSMENT FORM. Name: Date: Age: Sex:
LIFE STYLE ASSESSMENT FORM Name: Date: Age: Sex: Please answer each of the following questions. If you require additional space, there s a blank Page at the end of the form. What is your purpose in coming
More informationDiabetes and Heart Disease Awareness. Washington Newsletter Fall 2011
Diabetes and Heart Disease Awareness Healthy Living with Diabetes sm and Heart Healthy Living sm Washington Newsletter Fall 2011 Heart Disease What do a balanced diet, exercise, weight control and not
More informationBariatric Surgery Patient History Questionnaire
Bariatric Surgery Patient History Questionnaire Your appointment will be delayed if this form is incomplete please print legibly Personal Information Name Date SSN# (for insurance purposes) - - Date of
More informationIntegrative Nutrition Intake
Kristi Pink, MPH, RD, LDN Integrative Nutrition Kristi@sunuwellness.com Integrative Nutrition Intake Sunu Wellness Center 12455 Ridgedale Dr Suite 203 Minnetonka, MN 55305 P: 952.314.7035 www.sunuwellness.com
More informationFITNESS ASSESSMENT & WAIVER
Nutrition Counseling & Services/ Eat Well, Be Fit! www.eatwellbefit.com FITNESS ASSESSMENT & WAIVER Client Name: Date: Date of Birth: Age: Sex: Address: City: State: Zip: Phone: (Home): ( ) (Work): ( )
More informationMY PERSONAL ROADMAP WORKBOOK
FINALLY. Celebrate your successes, even the small ones! Learn from your efforts that don t turn out as you hoped or expected. If you do this, you can t fail! Set yourself up to succeed. Remember.. Most
More informationPersonal Diabetes Passport
Personal Diabetes Passport Contact information: Name: Physician: Diabetes Education Centre: Dietitian: Ophthalmologist: Chiropodist: Type of Diabetes: Type 1 (T1DM) Increased risk for diabetes Type 2(T2DM)
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
More informationMedical History. Instructions. My telephone number is: 1 Tools Medical History
Medical History Instructions To do the best possible job with your heart failure, the doctor needs details about your history, including current and past medical problems, medications, health habits, and
More informationDo You Know Your Cholesterol Levels? Healthy Hearts, Healthy Homes
Do You Know Your Cholesterol Levels? Healthy Hearts, Healthy Homes Read other booklets in the Healthy Hearts, Healthy Homes series: Are You at Risk for Heart Disease? Do You Need To Lose Weight? Keep the
More informationMedicare Annual Wellness Visit Patient History
Grace Health Medicare Annual Wellness Visit Patient History Name Date Birthdate Languages Spoken Date of Last Wellness Visit Do you have an advance directive or living will? Yes Don t Know Want Information
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
More informationHEALTH RISK ASSESSMENT FOR ANNUAL PHYSICALS
HEALTH RISK ASSESSMENT FOR ANNUAL PHYSICALS Patient Name: DOB: PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do
More informationPATIENT QUESTIONNAIRE / ASSESSMENT
PATIENT QUESTIONNAIRE / ASSESSMENT Diabetes Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital Status:
More informationNew Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
More informationGender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
More informationRevitalize, Regenerate & Restore Office of Dr. Kashi Rai. Health Coaching Packet
1 Health Coaching Packet A health coach is knowledgeable in the process of health behavior modification. We work in partnership with our clients to assist them to enhance personal accountability, set goals
More informationAdult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
More informationNUTRITION EDUCATION PACKET
NUTRITION EDUCATION PACKET Date: DIRECTIONS FOR SUBMITTING NUTRITION EDUCATION PACKET: 1. Complete the Client Information Page. 2. Complete the Nutrition and Physical Activity Assessments. 3. Complete
More informationBARIATRIC PROGRAM PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY)
BARIATRIC PROGRAM PERSONAL INFORMATION PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY) Name: Date: Sponsor s SSN# - - Date of Birth: Age: Mailing Address: City: State: Zip: Mobile Phone: Home
More informationRecord-Keeping Charts
In this appendix, we have provided some useful charts for you so you can record information that s important to manage your diabetes. Use these charts to keep track of the information not only for yourself,
More informationBariatric Intake Form
Name Today s Date Age Date of Birth Phone Address How did you find us? Emergency Contact Name Relationship Phone Home ( ) Work ( ) Cell ( ) Address Physicians Primary Care Cardiologist Psychologist Sleep
More informationCase Study #4: Hypertension and Cardiovascular Disease
Helen Jang Tara Hooley John K Rhee Case Study #4: Hypertension and Cardiovascular Disease 7. What risk factors does Mrs. Sanders currently have? The risk factors that Mrs. Sanders has are high blood pressure
More informationAdult Initial Health History
Adult Initial Health History Name Today's Date First Middle Last Date of Birth Address Telephone Number (home)( ) (cell) ( ) (email address) Filling out this form Answering these questions will help your
More informationNew Patient Health Information
MEDICAL FACULTY ASSOCIATES DEPARTMENT OF GENERAL SURGERY DIVISION OF BARIATRIC SURGERY 1011 NEW HAMPSHIRE AVE, NW WASHINGTON, DC 20037 New Patient Health Information The information obtained from this
More informationEating Healthy on the Run
Eating Healthy on the Run Do you feel like you run a marathon most days? Your daily race begins as soon as your feet hit the floor in the morning and as your day continues you begin to pick up speed around
More informationMedicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
More informationName (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:
SCREENING APPLICATION NOTE: THIS APPLICATION MUST BE COMPLETED BEFORE YOU CAN ENROLL IN THE NEW DIRECTION (ND) SYSTEM. PLEASE ANSWER EVERY QUESTION. PLEASE PRINT CLEARLY. Date: Name (Last Name, First Name):_
More informationABOUT TYPE 2 DIABETES
ABOUT TYPE 2 DIABETES Because the more you know, the better you ll feel. What You ll Find Attitudes and Beliefs Type 2 Diabetes What Is It? Where You ll Find It Page 4-5 This booklet is designed to help
More informationDate of Birth: City: State: Zip: Home phone: Who is your primary care physician?
PERSONAL INFORMATION Name: Address: Date of Birth: Mobile phone: City: State: Zip: Home phone: Email: Who is your primary care physician? Phone: How did you hear about The Nebraska Medical Center Bariatrics
More informationDiabetes Self-Care Information and Record Booklet
Diabetes Self-Care Information and Record Booklet Your personal guide... what you do each day really matters. This document is available online at www.wisconsindiabetesinfo.org What is Diabetes? Diabetes
More informationPlease complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
More informationNUTRITION SCREENING QUESTIONNAIRE
1 Name: Date of Birth: Home/cell number: Height: Lowest weight in last 5 years: Physician s Name: Date: Email address: Work phone number: Weight: Highest weight in last 5 years: Physician s Tel. Number:
More informationByers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
More informationYouth4Health Project. Student Food Knowledge Survey
Youth4Health Project Student Food Knowledge Survey Student ID Date Instructions: Please mark your response. 1. Are you a boy or girl? Boy Girl 2. What is your race? Caucasian (White) African American Hispanic
More informationHILLCREST CENTRE FOR HEALTH 832 St. Clair Ave W. Toronto, ON M6C 1C1 Tel: Fax:
Adult Intake Name Date of first visit Date of birth (M/D/Y) Gender M F Address: E-mail Address: May we add you to our mailing list? (Your email address will not be shared): Y N Telephone number: Home:
More informationStandard Medicare and Managed Medicare plans pay for diabetes education.
614-447-9495, ext. 1 You are scheduled to attend a series of four diabetes education classes. If you are not able to attend the class series, we ask that you cancel your appointment at least 48 working
More informationAdult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
More informationo Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
More informationLifestyle and Metabolic Medicine
Lifestyle and Metabolic Medicine New Patient Intake Form - fax completed form to 206.720.7448 or bring to your first appointment. Demographics First Name Date of Birth Mailing Address City, State, Zip
More informationKnow the Limits for Every Body
Know the Limits for Every Body Unit Facilitator s Guide Length of Lesson: 45 minutes 1 hour Unit Objectives As a result of this lesson, individuals will: Understand that limiting fats, sugars and oils
More informationCity: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:
1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
More informationType 2 Diabetes. Care for your body today for a healthier tomorrow
Type 2 Diabetes Care for your body today for a healthier tomorrow Understanding diabetes You may already know that having diabetes means you have too much sugar in your blood. Why do you have high blood
More information