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Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Patient Phone Number:___________________ Patient Email:___________________________ Primary Care Provider Name : _________________ Primary Care Provider Contact Information: Address______________________________ ____________________________________ Phone Number: _______________________ Diabetes New Patient Questionnaire The following questionnaire is intended to help us better evaluate and treat your medical conditions. We appreciate you filling it out in its entirety. If you do not want to answer a questions, leave it blank and discuss it privately with your physician at today’s visit. Please hand completed questionnaire to the nurse at the beginning of the initial visit. Diabetes History: 1. When were you first diagnosed with Diabetes?__________________ 2. What type of Diabetes were you diagnosed with?_________________ 3. Have you ever been hospitalized for elevated sugars, if so, how many times and when was the last time?________________________________________ 4. Have you ever been hospitalized for low sugars, if so how many times and when was the last time?______________________________ 5. Have you ever had DKA (Diabetic Keto-Acidosis)?______________________________________ 6. At what sugar level do you start feeling that your sugar is too low?________________________ 7. What symptoms do you have when your sugar is low?________________________________ 8. How many times a day do you check your sugars?___________________________________ 9. If you are using insulin, when did you start taking insulin?__________________________ 10. What other medications have you tried for your diabetes in the past and what is your reason for no longer being on them?_____________________________________________________________ 11. Do you wear an emergency bracelet?_____________________________________________ 12. Do you drive, if so, do you carry a snack and glucose meter in your car?__________________ 13. How often do you check your feet?___________________________________________ 14. Do you know what to do with your insulin and glucose checks if you are sick?______________ 15. Who has been managing your diabetes recently?___________________________________ 16. If you are using insulin or injection medication for diabetes, do you draw up and administer your own injections or does someone else do that for you?________________________________ 17. Do you have family or friend support to help you with your medical condition, and if so, who helps you?_________________________________________ 18. How do you organize your medications?____________________________ 19. What struggles do you feel limit optimizing your diabetes control?___________________________ 20. Do you want to improve your diabetes at this time?______________________________________ Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Medical History: please check all of the below conditions that you have been diagnosed with __ Anemia __ Asthma __ Rheumatoid Arthritis __ Bleeding disorder __ Breast Cancer __Thyroid cancer __Cataracts __Gastroparesis __Depression __Diabetes type 1 __Erectile dysfunction __Post-menopausal __Hypoglycemic unawareness __Low Potassium __Acromegaly __Histoplasmosis __Obstructive Sleep Apnea __Carpal Tunnel __Diabetes type 2 __Mental Illness __Glaucoma __Hepatitis __HIV/AIDS __ Kidney disease __Osteoporosis __Stroke __Thyroid disease __Skin Ulcers __Multiple miscarriages __Retinal disease __Vitamin D deficiency __Adrenal Insufficiency __Low Testosterone __Sarcoidosis __Obesity __Sexually Transmitted Infection __Other type of diabetes __Epilepsy/Seizures __Irregular heart rhythm __Cirrhosis __High blood pressure __Kidney stones __Gall bladder stones __Heart Attack __Positive PPD __Stomach ulcers __Brain tumor __Neuropathy __Elevated calcium __Cushing’s Disease __Lupus __Gestational Diabetes __High Cholesterol Medications List all the prescribed medications, vitamins, and herbal medications you are currently taking. Name of medication, dose, and frequency: 1.___________________________________________________ 2.___________________________________________________ 3.___________________________________________________ 4.___________________________________________________ 5.____________________________________________________ 6.____________________________________________________ 7.____________________________________________________ 8._____________________________________________________ 9._____________________________________________________ 10.____________________________________________________ 11._____________________________________________________ 12.______________________________________________________ 13._______________________________________________________ 14._______________________________________________________ 15._______________________________________________________ 16.______________________________________________________ What is your current Birth control method: _______________________________ Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Allergies and reaction to allergen: Medications: ______________________________________ Food:_______________ Latex_________________ Iodine:_____________ Tape:________________ Animals:_______________ Other:______________ Surgical History: List the year of any operations or procedures you have had that are listed below. If you do not remember the year, you may place a checkmark next to the procedure. _____ Breast Growth removal _____Hip surgery _____Knee surgery _____ Carpal Tunnel Release _____Nasal/sinus surgery _____Plastic surgery _____Cataract surgery _____Colon polyp removal _____prostate surgery _____ Cesarean section delivery _____thyroid surgery _____Tubal Ligation _____Gall bladder removal _____Vasectomy _____Organ transplant _____Heart catheterization _____Spine surgery _____Adrenal surgery _____Hernia repair _____Parathyroid surgery _____Bone fracture repair _____Hysterectomy _____Weight loss surgery _____Brain surgery _____Lasik Eye surgery _____Retinal laser therapy _____Amputation _____Pancreatic surgery _____steroid injection _____Blood Transfusion Family History: Are you adopted: ___ Yes ___No Check any illnesses which have occurred in your blood related relatives, Please specify B-Brother, FFather, M-Mother, C-Child, S-Sister, G-Grandparent, A-Aunt, U-Uncle ____Breast Cancer ____Lung Cancer ____Prostate Cancer ____Thyroid Cancer ____Colon Cancer ____Other Cancer ____Lupus ____Hyperthyroidism ____Diabetes type 1 ____Mental Illness ____Osteoporosis ____High Cholesterol ____Tuberculosis ____Adrenal Insufficiency ____Rheumatoid Arthritis ____Pituitary problem Female Reproductive HIstory: How many times have you been pregnant:_______ How many of the pregnancies went to full term:_____ How many of the pregnancies were premature:______ How many abortions have you had?_______ How many miscarriages have you had?__________ How many children are living now?____________ What year was your last pregnancy?______________ When was your last period?_________ At what age was your first period?__________ Social History: Occupation:__________________ ____Diabetes type 2 ____Heart Attack ____High blood pressure ____High calcium ____Stroke ____Kidney disease ____Hypothyroidism ____Obesity Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Highest Level of education:______________ Preferred Language:_________________ Do you have sex with: ____Men ____Women ___Both Men and Women Marital Status: _____Married _____Single ____Divorced ____Widowed List your Ethnic Origin: ____Latino ____ Not Latino List your Race: _____American Indian/Alaskan Native ____Asian ____Black/African American ____ Native Hawaiian/Pacific Islander ____White ____ Other Lifestyle: 1. How many days per week do you exercise?_________ For how much time?________ 2. What kind of exercise do you do?___________ 3. Do you follow a special diet: ___ diabetic ___Vegetarian __Vegan __low carb ___ low Fat __Low calorie ___low protein ____Other 4. how many meals do you eat a day and at what times? __Breakfast ___________ __Lunch ______________ __Dinner ______________ __Other________________ 5. How many snacks do you eat a day and at what times? ___Morning snack________ ___Afternoon Snack____________ ___Bedtime snack________ ___Other__________________ 6. What time do you wake up?____________ 7. What time do you go to sleep?__________ 8. Do you currently use tobacco or have you used tobacco in the past ? ____ Yes ____ No If you use tobacco: How often:____________ For How Many Years:___________ What kind of tobacco: ___________________ If you use cigarettes, how many cigarettes a day do you use? _________________ Have you ever tried to quit using tobacco?_____________________ If you quit Tobacco, what year did you quit?_________ 9. Do you currently drink Alcohol or used to consume alcohol in the past? ____Yes ___No If Yes, How many days a week do you consume alcohol?________ What kind of alcohol do you drink?__________ How much alcohol do you drink at one sitting?_________ 10. Do you currently use or have you used any drugs in the past? ___ Yes ___No If you have or are currently using drugs, What kind of drugs?_____________________ When was the last time you used drugs?____________________ Did you ever use Intravenous Drugs? 11. Have you ever tried to lose weight?_____ Yes _____No If Yes, How many pounds did you lose?___________ What worked to help you lose weight?_____________________________ Are you currently interested in losing weight?______ Yes _______No 12. How many times a week do you eat fast food?_______________ 13. How many days a week do you drink soda or concentrated sugary drinks?_________________ Health Maintenance: 1. When was the last time you saw the dentist?_________ What is the contact information for your dentist?______________________________ Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ 2. When was your last eye exam and what did it show?_____________________________ What is the contact information for your eye specialist?__________________________ 3. When was your last Flu vaccine:_____________ 4. When was your last pneumonia vaccine?__________ 5. When was your last Shingles vaccine?____________ 6. When was your last hepatitis A vaccine?__________ 7. When was your last Hepatitis B vaccine?__________ 8. When was your last Tetanus vaccine?_____________ 9. When was your last test for osteoporosis?__________ 10. When was your last HgA1C and what was the result?________________ 11. When was your last Cholesterol test and what was the result?____________ 12. When was the last time you saw a foot specialist ?________________ If so, What is their contact information:_______________________________________ 13. When was the last time you saw a heart specialist?________________ If so, What is their contact information:___________________________________________ 14. When was the last time you saw a Kidney Specialist?____________ If so, What is their contact information:______________________________________ 15. When was the last time you met with a nutritionist or diabetes educator?_________________ 16. When was the last time you saw your primary care provider?___________ 17. When is your next appointment with your primary care provider?__________ Review of Systems: Have you recently experienced any of the below symptoms? If so, please circle and explain. Eyes: Double Vision Loss of vision Protruding eyes Eye pain Blurry vision change in vision Comments:________________________________________________________________ Ears, Nose, Throat: Loud snoring Thyroid enlargement Thyroid pain Thyroid nodule difficulty swallowing liquids difficulty swallowing solids frequent nose bleeds ear pain decreased hearing ringing in the ears Comments:_________________________________________________________________ Mouth: Poor dentition bleeding gums tooth abscess enlarged tongue ulcer in mouth New gaps in teeth Comments:_________________________________________________________________ Respiratory: Persistent cough Shortness of breath Wheezing Coughing up blood Stop breathing during sleep Comments:_________________________________________________________________ Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Cardiovascular Chest pain irregular heart beats chest pressure Comments:_________________________________________________________________ Gastrointestinal: Heartburn Diarrhea Constipation Blood in stools excessive bloating or belching Change in stool size Comments:_________________________________________________________________ Kidney/Bladder: frequent urinary tract infections blood in urine urinary frequency in daytime increased urination at night slow urinary stream urinary incontinence painful urination Comments:_________________________________________________________________ Musculoskeletal: chronic joint pain chronic back pain muscle weakness limitations on walking or running Frozen shoulder change in shoe size change in ring size Leg swelling Comments:_________________________________________________________________ Neurological: burning Pain or numbness or hands or feet repeated headaches recurrent dizziness loss of consciousness loss of balance Tremors Comments:_________________________________________________________________ Skin: dry skin hair loss oily skin dry hair oily hair excessive hair on face, chest, abdomen, or back in a female varicose veins Rash poor wound healing Comments:_________________________________________________________________ Infectious Disease: Fevers Chills International Travel MRSA Tuberculosis Comments:_________________________________________________________________ Endocrine: Significant weight loss significant weight gain increased thirst Comments:_________________________________________________________________ Psychiatric: Anxiety Depression Insomnia loss of interest thoughts of harming yourself Fatigue loss of sexual desire Thoughts of harming someone else Name of Patient:______________________ DOB:_____________ Medical Record Number: _________________ Comments:_________________________________________________________________ Female Reproductive: Irregular periods painful periods heavy periods Spotting between periods Vaginal itching Irregular vaginal discharge Vaginal rash or lesion Nipple discharge Breast mass Vaginal dryness Painful intercourse Hot flashes Comments:_________________________________________________________________ Male Reproductive: weak erection blood in semen no morning erection decreased sexual drive Ulcer or lesion on genital area Penile discharge Comments:_________________________________________________________________ I attest that the above answers are truthful to my best of knowledge. Patient Signature ________________________________________ Patient Name____________________________________________ Date of Signature_________________________________________ Questionnaire reviewed by: Physician Signature:_______________________________________ Physician Name:__________________________________________ Date of Signature:_________________________________________
