Initial Consultation Forms Logo

  • PROVIDER TRAINING: PRE-TREATMENT MEDICATION PREP

    Regarding insulin or other blood glucose/diabetes medications:

    target glucose is to be around 150 or above night before treatment, take half of the normal dose of insulin of other diabetic medications normally taken if patient takes long-acting insulin and blood sugar is >350 mg/dl before bedtime, inject half the usual amount: if <350, DO NOT TAKE long-acting insulin the night before

    take prescribed dose of insulin or other diabetic medications as directed the night before treatment

    on the day of treatment, take HALF of prescribed dose in the morning

    turn off 2 hours prior to treatment turn back on immediately after treatment.

  • NEW PATIENT CONSULTATION FORM

  • Confidentiality Notice: Please note that this form is part of the confidential medical record and will be kept in your Diabetes Relief file. Information contained here will not be released to any person except under your authorization.

    Preferred Name: Date of Birth: In brief, what main concern(s) and/or interest(s) bring you to our office?

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  • NEW PATIENT CONSULTATION FORM

    Medical Conditions: Please select all diagnosed medical conditions and appropriate details.
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  • Family History

    Please list family health information if known, with emphasis on significant, chronic conditions.

  • Father

  • Mother

  • Brother(s)

  • Sister(s)

  • Grandparent(s)

  • Diabetes-specific Health Information

    • Neuropathy 
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    • Retinopathy 
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    • Kidney Dysfunction 
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    • Habits 

    • If known, what does your blood sugar range at the following times?

    • End 

  • SYMPTOM REVIEW

  • Please check current issues and symptoms, if a chronic concern or a recent significant change.

  • Clear
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  • EQ-5D-5 LEVEL

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  • Under each heading, please check the option that best describes your health TODAY.

  • EQ-5D-5 LEVEL

    • We would like to know how good or bad your health is TODAY.
    • This scale is numbered from 0 to 100.
    • 100 means the best health you can imagine. 0 means the worst health you can imagine.
    • Imagine marking an X on the scale to indicate how your health is TODAY.
    • Now, please input the number you would mark on the scale in the box below.
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  • VF-14 QOL Questionnaire

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  • Because of your vision, how much difficulty do you have with the following activities? Select the option that best describes how much difficulty you have, even with glasses. If you do not perform the activity for reasons unrelated to your vision, select "n/a".

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  • MICHIGAN NEUROPATHY SCREENING INSTRUMENT

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  • History (To be completed by the person with diabetes) Please take a few minutes to answer the following questions about the feeling in your legs and feet. Check yes or no based on how you usually feel.

  • Assessment Questions

    Blood Sugars

  • What are your blood sugar readings?

  • Diet

  • Exercise

  • Energy

  • Sleep

  • Wounds

  • Neuropathy

  • Retinopathy

  • Nephropathy

  • Erectile Dysfunction

  • Goldberg Depression Test (PHQ-9)

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  • Please complete the following. How often have you been bothered by any of the following problems over the last 2 weeks?

  • PDQ-39 QUESTIONNAIRE

  • Due to having Parkinson's disease, how often during the last month have you...

  • Should be Empty: