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: single married divorced widow/widower What hours do you work? Occupation: Ethnic Group: Black Caucasian Hispanic Other: Do you drink alcohol? YES NO If so, what type of alcohol? # of drinks per week or # of drinks per year Do you smoke? YES NO # of packs per day for years Are you a past smoker? YES NO Date stopped: Do you use any type of street or recreational drugs (cocaine, marijuana, etc.)? YES NO Do you exercise? YES NO If so, what type? How often? DIABETES STATUS Do you wish to learn more about how to take care of your diabetes? YES NO How would you rate your overall health? EXCELLENT GOOD FAIR POOR Is the diagnosis of diabetes new to you within the last 6 months? YES NO If no, how long have you had diabetes? Have you ever had diabetes classes? YES NO In the past year, have you been in the emergency room due to your diabetes? YES NO In the past year, have you been hospitalized due to your diabetes? YES NO Have you ever been told that you have a complication related to your diabetes? YES NO If so, what was the problem? When did you last see an eye doctor? Dr. s name Have you ever been told that you have any of the following? YES NO If so, which? (Please circle) glaucoma cataracts retinopathy (eye damage due to diabetes) Have you had any amputations? YES NO Have you had hypoglycemia (low blood sugar or insulin reaction)? YES NO If so, how did you know you were low? How often do you have hypoglycemia (low blood sugar)? What time of day do you have hypoglycemia? What do you do when you have hypoglycemia (low blood sugar)? Do you check your blood sugar at home? YES NO How often? 1
What brand of meter do you use? PATIENT QUESTIONNAIRE (continued) _ If you already check your blood sugar, please check before meals and bedtime prior to your visit for four days and record them here: Breakfast Lunch Supper Snack What word(s) best describes how you feel about your diabetes? SHOCKED ACCEPTING SCARED CHALLENGED ANGRY OVERWHELMED DEPRESSED LONELY DENIAL Do you adjust your diet or insulin dose in anticipation of exercise? YES NO If so, please describe: Describe your understanding of when to call a doctor about your diabetes: What do you do to take care of your feet? Do you see a podiatrist? How often do you see your dentist? Do you have dental problems YES NO Over the last 6 months, have you (circle one): Lost weight? Gained weight? Maintained weight? Number of pounds lost or gained? If you lost weight, were you trying to lose weight? YES NO What would you like to weigh? Have you ever had instructions on a diabetic diet? YES NO If so, when? Are you following a diabetic diet? YES NO If so, what calorie level? Have you ever been on any other diet? YES NO If so, please list: Do you have any dietary restrictions? YES NO If so, what Caffeine use? YES NO if yes, how much/day? Do you eat red meats? YES NO If yes, how much /week? Do you eat fried foods? YES NO If yes, how much in a week? Please list approximate times that you eat: 1st meal, 2nd meal, 3rd meal Other Do you ever skip meals? YES NO If so, which meal(s)? 2
How many times do you eat away from home? times per week times per month Who fixes your meals at home? List below the amount and type of food you have eaten for the past 2 days Breakfast Lunch Supper Snack Day 2 Day 1 POSSIBLE TEACHING NEEDS Are you having any problems with the use of your hands? YES NO If so, what type of problem? Do you have hearing problems? YES NO Are you overly concerned about your ability to pay for your diabetes care? NO SOMEWHAT YES Comments: Do you feel that you learn best by: (please circle) SEEING HEARING DOING Have you had any new stress within the last 3 months? YES NO Are you able to read? YES NO Do you speak English YES NO Do you read English? YES NO Do you have vision problems that make it difficult to read? YES NO If so, what? Have you ever been diagnosed with a learning disability? YES NO If so, what? Do you have any religious or cultural beliefs or practices to include in your care? YES NO If so, what? What is the highest grade of school that you completed? Who lives in your household? Whom do you consider as a support person? What relationship is this person to you? 3
GENERAL HEALTH STATUS 1 Family History Father: living dead age of death (if applicable) cause of death Mother: living dead age of death (if applicable) cause of death Have you had a family member with any of the following? If so, check the correct box. Father Mother Children Brother / sister Grandparents Father Mother Children Brother / sister Grandparents Tuberculosis Heart disease Kidney disease Kidney stones High blood pressure Stroke High cholesterol Breast cancer Diabetes Thyroid disease Genetic disease Osteoporosis Bone fractures Calcium problems 2 Please circle any health problems / procedures you currently have or have had in the past: Adrenal Gland Disorder Gallbladder removed Liver Disorder Appendix removed Glaucoma MRSA Cancer type Immune System Disorder Thyroid Disorder Cataracts High Blood Pressure Osteoporosis Congestive Heart Failure High Cholesterol Pancreatitis Diabetes Coronary Artery Disease Parathyroid Disorder Heart Attack Poor circulation in feet, legs Chronic Lung Disease (COPD) High Blood Pressure Mental Illness Pain Kidney Disease Hepatitis Blood Disorder Kidney Stones Pituitary Disorder Sleep Apnea CPAP Stroke Asthma Vasectomy Hysterectomy partial total Thyroidectomy (removal) total partial right Have you had the pneumonia vaccine? YES NO If so, when? Do you take flu shots annually? YES NO 4
4 Please circle any symptoms that you are currently experiencing: General: weight gain weight loss fatigue insomnia fever lack of energy HEENT: blurred/double vision lightheaded/dizziness eye pain eye swelling protruding eyes visual field changes seeing spots unusual dark circles around eyes nosebleeds sore throats difficulty swallowing voice changes mouth sores loss of taste abnormal taste bleeding gums frequent headaches Lymph: swollen glands lumps in neck Respiratory: shortness of breath wheezing snoring coughing unusual phlegm/mucus Cardiac: palpitations shortness of breath chest pain/pressure irregular blood pressure Endocrine: change in libido breast pain/tenderness breast discharge infertility hair loss Hair growth slow healing heat/cold intolerance hot flashes chills excessive sweating increased thirst unusual bruising rash itching easy bruising GI: nausea vomiting bloating abdominal pain heartburn diarrhea constipation blood in stool frequent bowel movements GU: blood in urine painful urination urinary incontinence increased urination unusual vaginal discharge irregular menstrual cycles painful menstrual cycles absence of menstrual cycles erectile dysfunction testicular pain/swelling Extremities: swelling muscle pains muscle cramps joint pain/stiffness Skin: change in nails dryness change in skin color skin sores unusual marks on skin Neurologic/Psych: seizures tremors/shakes anxiety depression irritability confusion difficulty with memory hyperactivity numbness tingling Women Only:/ Do you have children? YES NO If so, how many? Were you diagnosed with diabetes while pregnant? YES NO Any problems with the birth of your children? YES NO If yes, please explain: Do your children have medical problems? YES NO If yes, please explain: How old were you when menstrual periods first began? Are they regular? YES NO How many days do the periods last? How frequent? Date of last one: 5
5 Date of last Pap smear: Results: Date of last mammogram: Results: Do you have any reactions or allergies to medicine, food, latex, dyes or other? YES NO If so, please complete: Item Reaction Item Reaction 6 Please list ALL medications that you take: breakfast lunch supper Metformin 1000 mg 500 mg Name of Medicine Example Lantus Avandia 8 mg bedtime 14 units Name of Medicine breakfast lunch supper bedtime 6
PATIENT PROVIDER CARE LISTING Please list ALL physicians you are currently receiving care from: Name: Street Address: City: State: Zip: Phone number including area code: ( ) Name: Street Address: City: State: Zip: Phone number including area code: ( ) Name: Street Address: City: State: Zip: Phone number including area code: ( ) Name: Street Address: City: State: Zip: Phone number including area code: ( ) PREFERRED PHARMACY INFORMATION Local pharmacy information: Name: Address: Phone: ( ) Mail Order pharmacy Information: Name: Address: Phone: ( ) LABORATORY INFORMATION: Name: Phone: ( ) Please sign when completed: 7
This questionnaire has been completed by: Relationship to the patient: Date: 8