Date of Birth. Black/African American. What is your occupation? Retired? Yes No

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1 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 White/Caucasian Black/African American Other Hispanic, Chicano, Latino, Mexican Do not know What is your occupation? Retired? Middle Eastern Describe your education: 8th grade or less Some high school High school graduate/ged Some college College degree (BA/BS) Graduate degree What is your primary language? Do you have difficult with: Physical difficulty Hearing Seeing Writing Reading English as a second language None of the above Who do you live with? Alone With spouse/partner With spouse/partner and children With parents only With children only With other family members/friends Who helps you with your diabetes? Self Spouse/partner Child Non-relative Other None of the above Do you have financial resources to care for your diabetes? Do not know Do you have emotional resources to care for your diabetes? Do not know What do you feel are major stresses in your life? How do you manage your stress?

2 HEALTH STATUS: What is your current height? feet inches What is your current weight? pounds What are your most recent lab results? (if you don t know, leave blank) A1c: Blood pressure: Total cholesterol: HDL: LDL: Triglycerides: Fasting Blood Glucose: Urine Protein: State your general feelings about your overall health: In the past 12 MONTHS, have you had: Hospital Admissions? Emergency Room Visits? Primary Care Doctor Visits? Specialist Doctor Visits? Eye Exam? Yes No Dental exam? (in last 6 months) Flu Vaccination? Date: Pneumonia Vaccination? Date: How many times? What for? A comprehensive foot exam by your doctor? (to check circulation, nerves) Do you have a family history of Diabetes? YES: mother father brother/sister aunt/uncle grandparent NO family history Other family with diabetes:

3 DIABETES STATUS: Have you had any previous diabetes education? Do not know If Yes, date you received education: Where did you receive education? What type of diabetes do you have? Type 1 Type 2 Gestational Do not know When were you diagnosed? Month: Year: Do you monitor your blood sugar? If Yes, answer the following questions How often? times each Day or Week What time of day do you normally check? before breakfast Average reading? after breakfast Average reading? before lunch Average reading? after lunch Average reading? before dinner Average reading? after dinner Average reading? at bedtime Average reading? other time(s) Average reading? What meter are you using? Do you perform a urine ketone test? If yes, how often? Have you had a recent episode of HIGH blood sugar? Do not know If yes, what was your blood sugar value? What symptoms did you have? What actions did you take? Have you had a recent episode of LOW blood sugar? Do not know If yes, what was your blood sugar value? What symptoms did you have? What actions did you take?

4 OTHER MEDICAL/SOCIAL HISTORY: List any allergies you have: Have you been diagnosed with: Coronary artery disease: Heart attack: High blood pressure: Stroke (CVA/TIA): Peripheral vascular disease (poor leg circulation): If yes, have you had an amputation? Neuropathy (nerve damage): Nephropathy (kidney damage): If yes, are you currently on dialysis? Have you had a kidney transplant? Retinopathy (diabetes changes in the retina): If yes, have you had laser treatment for this? Do you have blindness from it? Do you have cataracts? Other issues? High cholesterol: Depression: Other medical conditions not listed above: Do you use tobacco? Quit If yes, how much do you smoke: packs per day For how many years? If you quit, how long ago? years Do you drink alcohol? Quit Do you drink regularly (a few times per week) or socially (a few times per month)? Regularly Socially How much alcohol do you use? drinks per week/month If you quit, how long ago? Do you examine your feet at least once a week? Are you experiencing any sexual problems? If yes, have you sought treatment for your sexual problems? Was the treatment for your sexual problems successful? For Women: Number of Pregnancies: # of Live Births: History of gestational diabetes? Currently pregnant? Contraceptive Method: Planning to get pregnant? Had a baby weighing 9 lbs or more? Reached menopause?

5 NUTRITION & EXERCISE: Have you started eating differently since being diagnosed with diabetes? If yes, what kinds of changes have you made? Eat less Eat less fat Eat less sugar Eat more vegetables Drink less soda/juices Other: How many times a day do you eat? One Two Three Four or more Which meals do you tend to skip? Breakfast Lunch Dinner Who does the cooking in your house? Self Spouse Other How many times per week do you eat out? Do you have any special dietary needs? Does your culture or religion require fasting or dietary restrictions? Do you exercise? If yes, what type of exercise do you do? Walking Running Swimming Golfing Dancing Bike riding Tennis Aerobics Weight lifting/strength training Sports (basketball, softball, etc. Other During a usual week, how many times do you exercise? How long do you usually exercise? minutes IF YOU ARE NOT EXERCISING: Do you have limitations that prevent you from exercising? If yes, please list here: Which activity level describes you best? Sedentary Typical activities of daily living (getting dressed, going to work, housework) 1.0 (GDM); (AF) Low Active minutes moderate activity 1.12 (GDM); (AF) Active 60 minutes or more of moderate activity 1.27 (GDM); (AF) Very Active 60 minutes or more of moderate activity AND 60 minutes vigorous OR 120 minutes moderate activity 1.45 (GDM); (AF)

6 MEDICATIONS: What medications do you currently take for diabetes? Name of Medicine Dose You Take How Many Times a Day? I don t take any medicine for my diabetes PERSONAL GOALS: What do you hope to learn/gain from this educational program? List 2 things you feel you need the most help with to improve your diabetes: 1. 2.

7 Name Date of Birth Today s Date Please answer the following questions with what your usual eating habits are. Include as many details as possible, including brand names and measurements. ***I usually wake up at: am pm I eat breakfast: Always Usually Sometimes Never If you selected Never, please go to the next section (morning snack). Breakfast Foods: I eat a morning snack: Always Usually Sometimes Never If you selected Never, please go to the next section (lunch). Morning Snack Foods: I eat lunch: Always Usually Sometimes Never If you selected Never, please go to the next section (afternoon snack). Lunch Foods: I eat an afternoon snack: Always Usually Sometimes Never If you selected Never, please go to the next section (dinner). Afternoon Snack Foods: I eat dinner: Always Usually Sometimes Never If you selected Never, please go to the next section (bedtime snack). Dinner Foods: I eat a bedtime snack: Always Usually Sometimes Never If you selected Never, please go to the next section (timing of bedtime). Bedtime Snack Foods: ***I usually go to bed at: STOP HERE am pm

8 For Office Use Only Calculating Caloric/Carbohydrate Needs 1. Simple form Underweight: kcals/kg Normal weight: kcals/kg Overweight: kcals/kg BMI BMI > kcals/kg kcals/kg (12.5 kcals/kg) Note: BMI not accurate for 5 10 or taller-don t use BMI= current kg divided by m2 (inches x ) 2. MIFFLIN ST-JEOR Equation Men [10 X wt ( kg)] + [6.25 X ht (cm)] [5 X age (yrs)] + 5 Women [10 X wt ( kg)] + [6.25 X ht (cm)] [5 X age (yrs)] Activity Factors: Sedentary Typical activities of daily living (getting dressed, going to work, housework) 1.0 (GDM); (AF) Low Active minutes moderate activity 1.12 (GDM); (AF) Active 60 minutes or more of moderate activity 1.27 (GDM); (AF) Very Active 60 minutes or more of moderate activity AND 60 minutes vigorous OR 120 minutes moderate activity 1.45 (GDM); (AF)