DIABETES QUESTIONNAIRE. NAME: DATE: Date of Birth: PRESENT ILLNESS. How did you find out you had diabetes? (check appropriate lines):

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1 JEAN PARK, M.D. Endocrinology and Metabolism Metropolitan Medical Associates at MedStar Good Samaritan Hospital 5601 Loch Raven Boulevard 3rd Floor Russell Morgan Building Baltimore, Maryland Telephone Fax PLEASE PRINT CLEARLY DIABETES QUESTIONNAIRE NAME:_ DATE: Date of Birth: PRESENT ILLNESS When did you find out you had diabetes? Year Age How did you find out you had diabetes? (check appropriate lines): 1. Incidental (i.e. found out while going to the doctor for something else). 2. While pregnant. 3. Symptomatic (i.e. felt bad, rapid weight loss, frequent urination, extreme thirst, blurred vision). 4. Hospitalized for diabetic ketoacidosis? 5. Hospitalized for diabetic coma (nonketotic)? Please give details about how you found out that you had diabetes and any hospitalizations you may have had for diabetes: Do you presently suffer from fatigue, weight loss, frequent urination, thirst, or blurred vision? Please give details: Have you ever been hospitalized for diabetic ketoacidosis (DKA)? DIET (check appropriate lines) Have you ever been given a meal plan for diabetes? When were you given the meal plan? How many calories? Other Were you instructed about the meal plan by a dietician? How often do you use a diabetic meal plan: Always Seldom Never When do you eat your meals? Breakfast Snack Snack Dinner Lunch Snack

2 What is your highest and lowest weight over the last five years? Highest Lowest Have you gained/lost weight over the last six months? Gained Lost. How many pounds? 2 MEDICATIONS Do you now or have you ever taken diabetes pills Date started Do you presently take them? Have you ever had any reaction to these medications? If yes, what type of reaction did you have?_ Type of diabetes pill? Dose Do you now or have you ever taken insulin Date Started Do you presently take insulin? Have you ever had any reaction to insulin?. If yes, give details: What is your current insulin type, dose, and schedule? Pre-Breakfast: Any sliding scale insulin?: Pre-Lunch: Pre-Dinner: Pre-Bed: Insulin Pump Date started: Are you presently on an insulin pump? What is your current insulin pump schedule (basal rates, boluses, frequency of site changes)? If you take insulin, where do you inject it (i.e. abdomen, thighs, arms, buttocks) and how do you rotate your sites? EXERCISE What type of exercise do you perform on a regular basis? How often? 1 day/week 2 days 3 days 4 days other. For what length of time? (10 minutes, 1 hours, etc.)? DIABETIC CONTROL Do you monitor urine, office blood glucose, home blood glucose glycohemoglobin. How often? Results? Do you use a glucose monitor?. What Brand?

3 3 PLEASE REMEMBER TO BRING IN YOUR GLUCOSE READINGS AND BLOOD GLUCOSE MONITOR TO EACH AND EVERY VISIT. HYPOGLYCEMIA (low blood sugar) How often do you have low blood sugar and how low is the reading? How do you feel when it is low? Have you ever been hospitalized for hypoglycemia (provide details) DIABETIC COMPLICATIONS If you have or have had problems with any of the following systems please explain in detail (dates, physicians, treatments): EYES: Who is your ophthalmologist, when was your last visit? KIDNEYS: HEART: HIGH BLOOD PRESSURE: CIRCULATION: DIGESTION:_ BOWEL REGULARITY: NERVES (numbness, pain, tingling in the legs): FOOT ULCERS: SEXUAL DYSFUNCTION: INFECTIONS:

4 DIABETES EDUCATION 4 Please check where appropriate. I have had formal diabetes instruction provided: In a classroom setting By my physician By a diabetes educator By a dietician Have not had instruction PERSONAL HEALTH SUMMARY What do you consider to be your main health problems? PAST MEDICAL HISTORY Have you ever had any of the following? (check appropriate lines): Scarlet Fever Rheumatic Fever Childhood diseases Tuberculosis AIDS Exposure to TB HIV(AIDS) Venereal diseases Hepatitis (yellow jaundice) Pneumonia Severe motor vehicle accident Please supply details: Please list each of your hospitalizations, date, and reason: DATE(Month/Year) HOSPITAL/PHYSICIANS REASON Please list any surgeries not listed above:

5 5 Please list the names of any medications you take, dosages, and the reason for taking them. Make certain to include all over the counter, herbal, eye, skin, or other medications: MEDICATIONS DOSAGE (mg,frequency) REASON FOR TAKING ARE YOU ALLERGIC TO ANY MEDICATIONS OR HAVE ANY MEDICATIONS MADE YOU SICK OR WORSE IN ANY WAY? Please list names of medications and reactions: Have you ever had a transfusion? Please list how much blood you received, the date, and any reaction(s): FAMILY HISTORY Please list the names, ages, and current health status of your parents, siblings, and children: Name Relationship Age Alive/Dead Health Problems Do any diseases run in your family? Please list:

6 SOCIAL HISTORY 6 Where were you born and raised? How much schooling have you had? What has been your main occupation and are you currently employed? What has been your most recent job? Marital Status? Religion? Do you ever smoke cigarettes, cigars, a pipe, or other form of tobacco? Please supply details (when you started, quit, how much do/did you smoke): Do you drink alcohol? Please supply details (how often, how much, when did you start, do you drink in the morning? Have you tried to cut back): Do you use any other drugs besides those listed above? Have you ever used intravenous (IV) drugs? Please supply details: Are you under any unusual stress at home/work? If so please explain: Who lives in your household? Do you have any close friends or family near your home? Please supply their names and telephone number if available: What do you do in your free time? REVIEW OF SYMPTOMS How would you describe your health? Good Fair Poor Are you sick a lot of the time? Do you tire easily? Do you sleep poorly? Have you lost your appetite lately? How tall are you now? What was your height at your tallest? Have you had: Anemia (tired blood) Kidney trouble Unexplained fevers Liver trouble Peptic ulcer Stroke Hemorrhoids (piles) Nervous breakdown Recent ear infection Recent runny nose Is your hearing poor Do you have constant ringing noises in your ears? Are you having trouble with your vision or sight? (PLEASE CONTINUE NEXT PAGE)

7 Do you wear glasses? Do you have pains in your eyes? Does your nose run or stop up a lot? Do you often have nose bleeds? Do you have sinus trouble? Are you missing many teeth? Do you wear plates or false teeth? Are you troubled by sore or bleeding gums? Do you have frequent sore throats? Have you ever had any serious skin trouble? Do you have pain or tightness in your chest when you are working or exercising? Do you get shortness of breath that wakes you up? Does your heart race or skip? Do you have swelling in your feet? Do you sleep on two pillows because of your breathing? Do you get cramps in your legs while walking? Do you usually have a cough? Have you ever coughed up or spit up blood? Are you short of breath when climbing stairs or up a hill? Have you had asthma (wheezing) attacks? Do you have trouble swallowing? Do you have stomach pains more than once a week? Are you troubled by vomiting or nausea? Do you often feel bloated or full of gas? Are you troubled by diarrhea? Are you troubled by constipation? Have your bowel habits changed recently? Have you ever had a bowel movement that was black, like tar, or bloody? Do you have trouble urinating (passing your water)? Does you have burning when you urinate? Have you ever passed kidney stones? Do you urinate more than two times a night? Have you ever noticed a swelling or lump in your neck, armpits, or groin? Do you have a goiter? Do you feel colder or warmer than most people? Do you often get leg cramps an night? Are your joints often painful or swollen? Have you ever had any serious trouble with your back? (PLEASE CONTINUE NEXT PAGE) 7

8 Have you broken any bones (including collapsed vertebrae?), which one(s)? Have you ever been told you have thin, brittle bones? Do you suffer from severe headaches? Do you often have spells of dizziness? Have you ever fainted (passed out)? Do you have numbness or tingling in any part of your body? Do you have weakness in any part of your body? Have you ever been knocked out? Have you ever noticed any shaking of your body? Have you ever had a seizure, fit, spell or convulsion (epilepsy)? Do you get upset or irritated easily? Do frightening thoughts keep coming to your mind? Have you ever thought of yourself as a worthless person? Have you felt that life is entirely hopeless? Do you frequently wish you were dead and your troubles were over? Were you ever in a hospital for your nerves? Are there any sexual problems you want to discuss? MEN ONLY 8 Have you ever had prostate trouble? Have you ever been told you have a low testosterone level? Have you taken testosterone shots? When was your last rectal examination? WOMEN ONLY How old were you when you first started having menstrual periods? How many times have you been pregnant? Did you have any problems with your pregnancies? If yes, please describe How many miscarriages or abortions have you had? Were there any times besides your pregnancies when your menstrual periods were not regular? Have you had bleeding between periods or after "change of life"? Have you ever taken estrogen or birth control pills? Do you have pain or lumps in your breasts? Do you think you have unusual vaginal discharge or itching? (PLEASE CONTINUE NEXT PAGE)

9 When was your last gynecological exam? Who is your gynecologist? When was your last mammogram? 9 PREVENTIVE MEDICINE When was your last influenza vaccination? When was your last pneumococcal vaccination? When was your last tetanus booster? If you had the Hepatitis B vaccine, when was it? When was your Varicella vaccination? If older than 18 and born after 1957, did you have an MMR? Do you wear seat belts routinely? Have you seen your dentist routinely? PERSONAL PHYSICIANS Please list all of your physicians, including their telephone and fax numbers and addresses: