• DIABETES CARE & EDUCATION PROGRAM

    Ready to better manage your diabetes? Fill out our patient self-assessment form!

  • PATIENT INFORMATION

  •  / /
  • Gender*
  • Format: (000) 000-0000.

  • LIFESTYLE HISTORY

    PHYCHOSOCIAL
  • Marital Status:*
  • Who is on your support team?*
  • Are you currently employed?*
  • Do you work shifts?*
  • Do you have difficulty with the following:*
  • Do you feel overwhelmed by the demands of diabetes?*

  • LIFESTYLE HISTORY

    NUTRITION
  • Do you count carbohydrates?*
  • Do you follow a special diet?*
  • What sweeteners do you consume on a regular basis?*

  • Please provide a sample of your meals for a typical day:

  • Please provide a sample of your snacks for a typical day:

  • LIFESTYLE HISTORY

    PHYSICAL ACTIVITY
  • Do you exercise?*
  • Are you active at work?*

  • MEDICATIONS

  • Please list all current medications.

  • Do you forget or omit any if your diabetes medications?*

  • DIABETES HISTORY

  • TESTING BLOOD SUGAR

  • Do you check blood sugar at home?*
  • Do you have questions about using you monitor?*

  • HYPERGLYCEMIA

  • Can you tell when your blood sugar is high?*

  • HYPOGLYCEMIA

  • Does your blood sugar run too low sometimes?*
  • Do you carry fast acting sugar with you? (glucose tabs, cady juice, etc.)*
  • Do you carry a Glucagon kit?*
  • Have you ever needed to use it?*

  • FEET HEALTH

  • Do you check your feet daily?*
  • Do you have any problems with your feet?*
  • Have you had any nerve damage (neuropathy) from diabetes?*

  • OPTICAL HEALTH

  • Have you had any eye damage (retinopathy) from diabetes?*

  • INSURANCE INFORMATION

  • Do you authorize the clinic to bill your insurance on your behalf for education?*
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  • Should be Empty: