HEALTH HISTORY QUESTIONNAIRE

Transcription

1 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 Black / Hispanic White/Hispanic Asian Indian American Indian Chinese Korean Japanese Vietnamese Unknown/Unspecified Other Marital Status: Single Married Divorced Partnered Separated Widowed Education: Less than High School High School/GED Trade/Vocational/College Occupation: Manual Labor Professional Self-Employed Homemaker Retired Unemployed Student Trade/Vocational Disabled Other Unknown Hours Worked per Week: less than More than 40 N/A Shift: Day Evening Night Rotating Have you ever used services at the Bon Secours Hospitals before? Yes No SOCIAL Who is your primary support person? Who is responsible for your care? With whom do you live? Self Spouse Self and Spouse Family Significant Other Self and Significant Child Friend Parent(s) Mother Father Shared Custody Grandparent(s) Other Family In-Home Support Neighbor Group Home Assisted Living No One Other Self Spouse Self and Spouse Family Significant Other Self and Significant Child Friend Parent(s) Mother Father Shared Custody Grandparent(s) Other Family In-Home Support Neighbor Group Home Assisted Living No One Other Self Spouse Self and Spouse Family Significant Other Self and Significant Child Friend Parent(s) Mother Father Shared Custody Grandparent(s) Other Family In-Home Support Neighbor Group Home Assisted Living No One Other How do you learn best? Do any of the following make learning difficult? What are you most interested in learning about in class? Notes: LEARNING PREFERENCES AND BARRIERS Computer Reading Lecture/Audio Hands On Demonstration Video Group Discussion None Vision Hearing Learning Disability Language Reading/Low Literacy Low Health Literacy Memory Loss Denial of Diabetes Work Schedule Lack of Family Support Competing Activities Food Issues Unresolved Eating Disorder Grief Financial Concerns Transportation Other

2 MEDICAL HISTORY DIABETES SPECIFIC Does anyone in your family have diabetes? Mother Father Brother/Sister Grandmother Grandfather Multiple Family Members Other None Unknown Have you been through diabetes education in the past? Yes No If Yes, how long ago? < 1 month ago 1-2 months ago 4-6 months ago 7-12 months ago 1-5 years ago 6-10 years ago > 10 years ago Unknown Have you met with a dietitian (nutritionist) in the past? Yes No If Yes, how long ago? < 1 month ago 1-3 months ago 4-6 months ago 7-12 months ago 1-5 years ago 6-10 years ago >10 years ago Unknown What was the reason for the visit? Have you been to the Emergency Room (ER) or admitted to the hospital in last 6 months: Yes No If Yes, was the visit related to your diabetes? Yes No FEMALE SPECIFIC Have you had a hysterectomy? Yes No Do you use birth control? Yes No Have you ever been pregnant? Yes No If Yes, how many times? How many live births? How many weighed more than 9 pounds? Have you ever had Gestational Diabetes? Yes No Are you considering getting pregnant? Yes No DIABETES COMPLICATIONS/COMORBIDITIES CHECK ALL AREAS IN WHICH YOU HAVE ANY PROBLEMS OR HAVE RECEIVED MEDICAL TREATMENT & CIRCLE PROBLEM Autoimmune Disorders HIV/AIDS Graves Disease Lupus Rheumatoid Arthritis Cardiovascular (Heart / Circulation) Stroke Congestive Heart Failure Coronary Heart Disease High Blood Pressure Heart Attack Peripheral Artery Disease Cancer Type: Chemo or Radiation? Teeth / Gums Dental Abscess Gingivitis Peridontitis Tooth Loss Eye Disease Cataracts Glaucoma Retinopathy Visual Loss/ Blindness Feet and Lower Limbs Amputation Charcot Foot Foot Ulcer Gastrointestinal (Digestion) Crohns Diverticulosis GERD Celiac Disease Irritable Bowel Pancreatitis Ulcerative Colitis Liver Disease Cirrhosis Fatty Liver Hepatitis Liver Failure Wilson s Disease Metabolism High Cholesterol/Triglycerides Metabolic Syndrome Obesity PCOS Thyroid Mental Health Muscular Fibromyalgia Multiple Sclerosis Alzheimer s Anxiety Attention Deficit Disorder Bipolar Disease Dementia Depression Eating Disorder PTSD Obsessive Compulsive Disorder Personality Disorder Kidney Disease Chronic Kidney Disease Dialysis : Peritoneal or Hemodialysis Kidney Transplant Nervous System / Nerve Disease Bladder Dysfunction Constipation Gastroparesis Hypoglycemia Unawareness Nocturnal Diarrhea Peripheral Neuropathy Postural Hypotension Sexual Dysfunction Lungs Asthma Chronic Bronchitis COPD Emphysema Sleep Apnea Joints / Bones Arthritis Degenerative Joint Osteoporosis Spinal Stenosis Other Medical Conditions

3 MEDICATIONS LIST YOUR MEDICATIONS OR ATTACH A LIST Medication Name: How Much Do You Take? When Do You Take the Medication? ALLERGIES TO MEDICATIONS Medication Name: Reaction: INSULIN PUMPS AND SENSORS Do you wear an insulin pump? Yes No If Yes, which one? Medtronic Animas Omnipod Basal rates: Sensitivity factor: Carb ratio: Target range: Do you use a sensor? Yes No If Yes, which one? Minilink Dexcom Low Target: High Target: GLYCEMIC CONTROL BLOOD GLUCOSE MONITORING Do you check your blood glucose (blood sugar)? Yes No If Yes, what is the name of your blood glucose meter? How often do you check your blood glucose (blood sugar)? 1x per day 2x per day 3x per day 4x per day Every other day Occasionally Rarely More than 4x per day What time of day do you monitor? Fasting Before Breakfast After Breakfast Before Lunch After Lunch Before Dinner After Dinner Bedtime 12 AM 3 AM Other Do you use alternate site testing? (for example, testing on your arm or leg) Yes No HYPERGLYCEMIA Have you ever experienced hyperglycemia (blood sugar >250 mg/dl)? (symptoms such as thirst, dry mouth, tiredness, frequent urination, or a blood sugar reading of over >250 on your blood glucose meter) How often do you have hyperglycemia? 1-3x per week 4-6x per week 7 or more times per week Rarely Yes Unknown No What time of day do you have hyperglycemia? Fasting Before Breakfast After Breakfast Before Lunch After Lunch Before Dinner After Dinner Bedtime 12 AM 3 AM Other Have you ever been hospitalized for high blood sugar? Yes No

4 HYPOGLYCEMIA Have you ever had hypoglycemia (low blood sugar)? (symptoms such as sweating, anxiety, trembling, or headaches) Yes No How often do you have hypoglycemia? What time of day do you have hypoglycemia? How do you treat hypoglycemia? 1-3x per week 4-6x per week 7 or more times per week Rarely Unknown Fasting Before Breakfast After Breakfast Before Lunch After Lunch Before Dinner After Dinner Bedtime 12 AM 3 AM Other Juice Soda Milk Sugar Candy Glucagon Glucose Tabs Food Do Nothing Other Have you ever required help from others, including the use of glucose gel, glucagon, or intravenous glucose, to treat low blood glucose? Are you able to feel when your blood glucose is low? Yes No Yes No MEASURES Please fill in with your most recent lab results or bring a copy of your lab results with you to your first appointment Date Height Weight (lbs) Date Blood Pressure Date Hemoglobin A1c Date Cholesterol LDL HDL Triglycerides (Tg) DIABETES MEDICAL MANAGEMENT Exam: Have you had these completed? Date: Notes: Foot Exam by a physician including check for nerve damage Yes No Dilated Eye Exam Yes No EKG/Stress Test Yes No Dental Exam Yes No Flu Vaccination Yes No Pneumonia Vaccination Yes No Bariatric Surgery Yes No Routine Medical Exam (Related to Diabetes) Yes No SELF-CARE BEHAVIOR ALCOHOL AND RECREATIONAL DRUGS Do you drink alcohol? Yes No If Yes, how much? Less than 1 drink per day 1-2 drinks per day More than 3 drinks per day Social Occasions Do you use recreational drugs? Yes No DIABETES IDENTIFICATION Do you carry identification that states that you have diabetes? Yes No

5 MEALS AND DINING Do you follow a meal plan? Yes No If Yes, what kind? Low Calorie Low Fat Carb Counting Dietary Exchanges Portion Control Heart Healthy (low fat/sodium) Plate Method Gluten Free Vegetarian Do you skip meals? Yes No Who is responsible for preparing your meals? Who is responsible for buying your food? How often do you eat out? Self Spouse Self and Spouse Family Significant Child Friend Parent(s) Grandparents In-Home Support Other Family Neighbor No One Other Self Spouse Self and Spouse Family Significant Child Friend Parent(s) Grandparents In-Home Support Other Family Neighbor No One Other Daily 4-6x per week 1-3x per week Every other week Occasionally Rarely Never Are you allergic or unable to tolerate certain foods? Yes No If Yes, please specify: Do you have any cultural or religious dietary practices? Yes No If Yes, please specify: MEDICATION ADHERENCE In an average week, how many times do you miss your diabetes medication(s): Never 1x per week 2-3x per week 4-6x per week 7 or more x per week What are the reasons that you miss your diabetes medication(s): Check all that apply: I forget The cost I have to take the medication too often My prescription is too hard to follow The side effects I don t need the medication I don t think the medication works Depression Other PHYSICAL ACTIVITY Do you participate in regular physical activity or exercise? Yes No Are you physically active for more than 150 minutes per week? Yes No What type of activity do you do? How long are you active per session? Aerobics Biking Cardiac Rehab Combination Running Sports/Athletics Stretching Swimming Walking Weights Other < 15 minutes minutes minutes minutes > 60 minutes How often are you physically active? <1x per week 1-2x per week 3-4x per week 5-6x per week >7x per week How would you rate the activity? Easy Moderate Difficult Strenuous Do you have any physical limitations that prevent you from being physically active or exercising? Yes No If Yes, please specify: SELF-ASSESSMENT How would you rate your current understanding of diabetes? Good Fair Poor How do you feel about diabetes? I accept it I am adapting I am angry I am in denial I am afraid I feel guilty I feel overwhelmed and confused I feel sad or depressed How would you rate your overall health? Good Fair Poor How important is your health to you? Extremely Somewhat Only when Ill Not Important How would you rate your stress level? High Medium Low Does diabetes interfere with anything in your life? Nothing Family/Social Activities Work/School Sports/Exercise Sexual Relations Finances Travel Other

6 SELF FOOT-CARE Do you examine your feet? Yes No If Yes, how often? Daily Every other day Occasionally Rarely Do you have any foot problems? None Callus(es) Bunions Neuropathy Ulcer Toenail Fungus Structural Deformity Other TOBACCO Do you have a history of tobacco use? Yes No Do you currently smoke? Yes No How much? <5 per day ½ pack per day 1 pack per day > 1 pack per day Occasionally Have you ever been referred to a program to help you stop smoking? Yes No Do you use any other tobacco? PAIN Are you experiencing any pain that you are unable to manage Yes No Current areas of pain? What causes or increases your pain? What time of day does your pain occur? Are you seeing a doctor for your pain? Yes No Have you had a cortisone injection? Yes No Where did you have the injection? How long ago? Please rate your pain on the following pain scale: (Circle the number or face) Name: DOB: