Diabetes Self Management Education & Support (DSMES)
Please complete the following form. Your answers will be submitted electronically directly to the Tomahawk pharmacy DSMES team.
PERSONAL INFORMATION
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone:
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email:
example@example.com
PRIMARY CARE PROVIDER INFORMATION
Provider Name:
*
Clinic Name (if known):
Clinic Phone Number (if known):
Format: (000) 000-0000.
DIABETES INFORMATION
Type:
*
Type 1
Type 2
Gestational
Pre-diabetes
Unknown
Year diagnosed: (If known)
Current method(s) of testing? (check all that apply)
*
CGM (continuous glucose monitor)
Meter
Other
None (I do not test my blood sugar)
What type of CGM (e.g. Dexcom G7, Libre 3 Plus, etc), if known:
What type of meter (e.g. FreeStyle, Contour, OneTouch, etc), if known:
How often do you test with your meter?
*
Please describe your "other" type of testing:
*
Current Diabetes Medications (if any):
INSURANCE INFORMATION
Type (check all that apply):
*
Medicare
Medicare Advantage
Commercial or Private
Medicaid
None or Self-pay
Insurance Company(s), if known:
Member ID(s), if known:
Medicare Number (found on the red/white/blue Medicare Card)
*
Back
Next
LEARNING GOALS
On a scale of 1 to 8 (with 1 being most important and 8 being least), rate the following in order of importance to you:
Understanding Diabetes
*
Healthy eating/meal planning
*
Medication education
*
Blood sugar monitoring
*
Preventing long-term complications
*
Physical activity and diabetes
*
Managing diabetes during illness
*
Stress management and diabetes
*
List any other topics of interest below:
What day of the week would you prefer we hold session(s):
*
No preference on day of the week
Weekdays (Mon-Fri)
Weekends (Sat-Sun)
What time of day would you prefer we hold session(s):
*
No preference on time of day
Morning (8am - noon)
Afternoon (noon - 4pm)
Evening (4pm - 7pm)
If you have a SPECIFIC day or time you'd prefer, please list below.
A QUESTION FOR YOU...
If your insurance does not cover this service, are you willing to pay out of pocket for it? *Please note: checking "yes" does NOT commit you to any sort of payment. This question is mainly focused on gauging interest in a self-pay option.
*
Yes
No
CONSENT TO CONTACT
By signing below, I give permission for the Tomahawk Pharmacy Diabetes Self-Management Education and Support Program (DSMES) team to contact me regarding diabetes education services.
*
Date:
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Month
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Day
Year
Date
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