Lifestyle & Pre-diabetes Questionnaire

Transcription

1 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 height: Current weight: Usual weight: Occupation: Retired? Current phone number: Do you give permission to leave a message at this phone number? Work Hours/Daytime Schedule: AM/PM to AM/PM Do you: Live alone? Live with others? If you live with others, please list: Have you had previous pre diabetes education? If yes, where? How would you rate your understanding of pre diabetes? Very Good Good Fair Poor Do you have difficulty with any of the following: Physical difficulty Seeing Writing ne of the above Hearing Reading English as a second language Barriers to care: Housing Utilities Food Transportation Please list health or medical conditions, including surgeries: Caregiver Activities of daily living Support network ne of the above Primary care physician: Pre diabetes physician: Do you have any food or drug allergies? If yes, please explain: Do you smoke?

2 If yes, how much? Former smoker, date quit? Do you drink alcohol? Daily Weekly Monthly Rarely Never What do you drink and how many drinks do you have? Do you currently have, or have Chest pain Heart disease Amputation you ever had? Eye disease High blood pressure Kidney disease Sexual difficulties Neuropathy How often do you see your pre diabetes physician? Date of last visit: Date of next visit: Have you ever had a dilated If yes, date of last exam: eye exam? Do you perform a daily foot exam? Have you ever visited a foot physician If yes, when and why? How often do you have a dental checkup? Have you ever had an EKG or cardiac stress test? If yes, what were the results? Has your weight changed over the past year? Has your weight changed over the past three (3) months? If yes, please describe: How comfortable are you with Extremely Quite a bit Somewhat your current weight? A little bit t at all What has been your weight range as an adult? What would you consider to be a healthy weight for you? Have you ever been on an extreme diet or fad diet? If yes, please describe: Are you interested in working to change your weight?, but not right now, but I will think about it, not right now, I m not interested

3 Pregnancy (women only) Are you able to become pregnant? Are you planning on becoming pregnant? Are you aware of the effects of diabetes on pregnancy, and of pregnancy on diabetes? Diabetes History When were you diagnosed with pre diabetes? List blood relatives with diabetes. Diabetes Questions and Knowledge: Have you received diabetes education before? If yes, when: Where: And with: Nurse Dietitian t sure How would you rate your understanding of diabetes: Very Good Good Fair Poor What do you hope to gain by receiving diabetes education? What is your biggest concern related to diabetes? How comfortable are you with your current diabetes selfmanagement? Extremely Quite a bit Somewhat A little bit t at all In what areas of diabetes management do you feel you need to make changes? How would you describe your motivation for change related to your diabetes? Are there any religious or cultural concerns you have relating to your diabetes? If yes, what? Healthy eating Problem solving Being active Coping/Support Stress management Monitoring Risk reduction Taking medication Other Highly motivated Moderately t motivated motivated

4 Blood Sugar Monitoring: Do you test your blood sugar? If yes, when and how often? Do you record your blood sugars? Physical Activity: What best describes your daily physical activity: Heavy Moderate Light ne Do you follow a regular exercise program or routine? If yes, what type of exercise do you do? How many days per week do you exercise? How long at each session? What time of day do you usually exercise? List any physical disability that prevents or limits you from exercise: Has your physician told you to avoid any specific exercise? Are you interested in becoming more physically active?, but not right now, but I will think it over, not now Stress Management and Support: Will anyone participate in the program with you? If yes, who? How does stress affect you physically or emotionally? Sleeping difficulties Depression Eating too much/too little Headaches Neck aches Other Is there stress in your life? If yes, what is the source of stress? Please use this space to explain more: Work Family Health How do you deal with stress? Are family or significant others supportive of your pre diabetes considerations? How do they show, or not show, support?

5 Nutrition: What nutrition information would you like to learn more about? Cooking Dining out Heart healthy nutrition Weight management Nutrition strategies to control blood sugar Other Do you have any specific nutrition questions you would like answered? How often does your eating habits leave you feeling deprived? Always Often Sometimes Never Please explain: Food label reading/supermarket shopping Who usually does your cooking? How many times a week do you eat away from home? Grocery shopping? Which meals are usually eaten away from home? What types of restaurants do you usually eat or carry out? Do you ever skip meals? If yes, which meals do you skip most often and why? How many meals do you usually eat per day? How many snacks to you usually eat per day? Do you get up during the night to eat or drink (other than water)? If yes, what? Describe any barriers you have to making changes in your eating habits: Do you eat for reasons other than hunger? If yes, please describe: Do you have trigger foods that often cause you to overeat? If yes, what foods? How often to you use nutrition strategies to control your blood sugar or for other health reasons? Please explain: Always Sometimes Often Never

6 Please write samples of your usual food and beverage intake and the times you eat your meals or snacks. BREAKFAST Time: LUNCH Time: DINNER Time: SNACKS Time(s): BREAKFAST Time: Please write down everything you ate and drank yesterday with the times. LUNCH DINNER Time: Time: SNACKS Time(s): Thank you for taking an important step to manage your health. RN Signature: Date: RD Signature: Date:

7 Patient Medication List (Grey areas are for office use only) When did you start taking Name of Medication this medication? Diabetes Medications taken orally (by mouth): Dose When do you take this med? Date Changed or Discontinued (For office use) Initials List diabetes medicines you used to take but have discontinued: Other medication(s) prescribed by your doctor. Include over the counter or other medicines, including vitamins or supplements, not prescribed by your doctor: Insulin and other injections (Symlin & Byetta):

8 Initials Signature Initials Signature ALLERGIES: LABEL: (For office use)