Multiple Daily Injection - Assessment Form

IDS Assessment Form

Contact Information

Section 2 (of 10) - Your Goals

Section 3 (of 10)- Health Background

Section 4 (of 10)- Dietary/Nutritional Information

READING LABELS – please use the following nutrition labels to answer the numbered questions below

Section 5 (of 10)- Physical Activity

Section 6 (of 10)- Diabetes management

Section 7 (of 10)- Injection insulin program

IDS Assessment Form

Multiple Daily Injection
IMPORTANT: Please do NOT complete these forms without contacting the Integrated Diabetes Services office to schedule an appointment.

(LOCAL) 610-642-6055
(TOLL-FREE) 877-735-3648
(Outside USA) 001-610-642-6055

*If you want to complete the form at a later date, please press the "Save & Continue Later" button (at the bottom of each page).
Contact Information
Today's Date

MonthDayYear
1. Who is filling out this form?
(Please fill out all questions as if you are the person with diabetes)
2. Patient's Name

First NameLast Name
3. Date of Birth
4. Gender identity
FemaleMale
6. Caregiver/s Name
(if patient is a child)/Significant Other/s
7. Relationship
8. Household members (role/age)
9. Type of Health Insurance
(include company name)
10. Address

Street Address

Street Address Line 2

CityState/Province

Zip Code
11. Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
12. Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
13. Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
14. Email
example@example.com
CellHomeWork
VideoPhone
17. How did you hear about us?
18. VERY IMPORTANT! Please list the software programs used to download your device data and generate reports, such as tidepool, glooko, carelink, t:connect, nightscout, sugarmate, and any manufacturer-specific programs. * Access information can be forwarded to: info@integrateddiabetes.com or entered at the bottom of this form.
19. Physician's Full Name

First NameLast Name
20. Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
22. Physician's Phone
Please enter a valid phone number.Format: (000) 000-0000.
23. Physician's Fax
Please enter a valid phone number.Format: (000) 000-0000.

Section 5 (of 10)- Physical Activity
83. How would you describe your current overall activity level?

84. Describe what you do to keep physically active, if anything. Make note of seasonal activities (even if not in current season)

85. Do you ever have trouble managing your blood sugar levels when exercising?
86. Do you routinely make adjustments to your diabetes treatment plan to manage your blood sugars during exercise?
87. How do you feel about exercise?
YesNo
YesNo
YesNo
91. If yes, what were the results of your exercise stress test?
92. Does anything prevent you from exercising?
93. What kind of exercise equipment do you have at home or in your community?
95. Have you been checked for osteoporosis and what were the results?
96. Have you ever been checked for sprue/celiac (gluten intolerance) and what were the results?

Rows	Lab Results	Date
HbA1c:
Total Cholesterol:
HDL Cholesterol:
LDL Cholesterol:
Triglycerides:
Microalbumin:
TSH:

Rows	Yes	No	I Don't Know
Retinopathy (blood vessel damage to the retina of the eye)
Nephropathy (kidney disease)
Coronary Artery Disease (blocked blood vessels leading to the heart)
Peripheral Vascular Disease (impaired circulation in the legs or feet)
Foot Infections/Ulcers
Peripheral Neuropathy (tingling, pain, or numbness in the legs or feet)
Autonomic Neuropathy (nerve disease affecting basic bodily functions)
Periodontal Disease (gum disease)
Range of Motion Limitations

Rows	Yes	No	I Don't Know
Dizziness when Standing
Leg Pain when Walking/Standing
Frequent Diarrhea
Ingrown Toenails
Vomiting/Abdominal Pain
Redness/Swelling of the Feet
Chest Pain/Shortness of Breath
Sexual Dysfunction
Genital Yeast Infections
Blurred/Obstructed Vision in one eye U
Urinary Tract Infections
Bleeding Gums w/Brushing
Numbness/Tingling
Discomfort with Chewing
Pain/Burning in Legs or Feet
Loose Teeth
Sleep problems: too little sleep
Sleep problems: too much sleep
Night Time Urination

Rows	Never	Daily	Weekly	Monthly	Every 2- 3 months	Every 6 months	Yearly	Every few years	Not sure
See your diabetes doctor?
Have a dilated eye exam?
Have your teeth cleaned professionally?
Brush your teeth?
Use Dental Floss?
Visit a Podiatrist?
Inspect your feet?
Have a Hemoglobin A1C checked?
Have your kidney function checked?
Have your cholesterol levels checked?
Have your thyroid levels checked?

Rows	Approximate time	Typical foods & drinks	Estimate of carbohydrates in this meal
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Evening Snack

Type of activity

How many minutes?

Pace/intensity

On what days?

What time(s) of day?

Rows	InsulinType	Time Taken	Units Carb Ratio	Sensitivity/correction factor
Morning/Breakfast
Mid-Morning/Snack
Midday/Lunch
Afternoon/Snack
evening/Dinner
Bedtime

Rows	1	2	3	4	5
Time of Day (AM/PM)
Target Blood Glucose (mg/dL)
Insulin Sensitivity Factor
Insulin to Carb Ratio (g/U)

USA Label	European Label

Rows	Insulin Type	Starts Working	Peaks	Stops Working
1
2
3