Download Harris Methodist Diabetes Management Center

Center for Diabetes Self-Management Education
Name: _____________________________________ How would you like to be addressed? ___________________
Address________________________________________________________________________________________ Sticker
Email address: ___________________________________________________________________________________
Home phone ____________________ Best or alternate phone ___________________________________
Marital Status (circle one): S M
D W
Ethnicity (circle one): Caucasian
African American
Hispanic Asian
Other ___________________
Who should we call in case of an emergency? (name & phone) __________________________________
Your physician’s name ______________ Diabetes physician’s name____________________________
Last level of education completed: (check one)

Middle school
How do you learn best? (check one)  Written materials
Medical History
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No

High school
 Verbal discussions
Have you been treated or diagnosed with any of the following?

College
 Video

Hands On
(Circle Yes or No)
Shortness of breath, asthma or chronic lung disease
Glaucoma or cataracts
Chronic pain If yes, where? _________________________________________________
Chest pain, heart disease or history of heart attack
High blood pressure
Noticed changes in skin recently? If yes, please describe___________________________
Have you been to ER, or admitted to a hospital? If yes, list reason _____________________
What surgeries have you had or planning to have? __________________________________
Diabetes History
Type of diabetes (check one):

Type 1 
Type 2 
Pre diabetes 
Gestational
Year of diabetes diagnosis ___________ In your words, what is diabetes? __________________________________
What do you expect from your appointment today? ______________________________________________________
Have you ever had instructions on diabetes or seen a dietitian? _____ (When?/Where?) _________________________
List family members with diabetes ____________________________________________________________________
Do you have a support person to help with your diabetes management? (circle one)
Yes or No
What is the most difficult thing about living with diabetes for you right now? __________________________________
What are your concerns, anxieties or fears about diabetes? _________________________________________________
Are you willing to make some changes to benefit your health? (circle one)
Height: ___________
Weight: ____________
(staff use only)
Yes or No
BMI: _____________
B/P _______________
(staff use only)
Texas Health Arlington Memorial Hospital, Diabetes Management Health History & Assessment, Page 1 of 5
(staff use only)
October 1, 2010
Family History
Do you have a family history of diabetes? (Circle Yes or No)
If yes, please identify which family member(s) Mother _________ Father___________
Chronic Complications / Health Screenings
How would you describe your general health? (check one) 
Good

Fair

Poor
Are you aware of the chronic complications that may develop when you have diabetes? (circle one) Yes
Are you currently experiencing any of the following?
If yes, please explain.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
or
No
(Circle Yes or No)
Blurred vision, changes or loss of vision
Weakness, fatigue, dizziness
Unusual or excessive thirst
Frequent urination, especially at night
Numbness, tingling, or swelling of hands or feet
Recurrent infections (yeast, urinary tract, or skin)
Difficulty with sexual function describe
Kidney disease
Periodontal disease
explain: _______________________________
explain: _______________________________
explain: _______________________________
explain: _______________________________
explain: _______________________________
explain: ______________________________
explain: _______________________________
explain: _______________________________
explain: _______________________________
Date of last exam
Cardiac stress test
Date of last flu shot
Dilated eye exam
Date of last pneumonia shot
Physical exam
Dental exam
Kidney function (microalbumin urine test)
Podiatrist or foot specialist
Lifestyle
Occupation: ________________________________ Work hours_____________________________________
Business Traveler? (circle one) Yes
or
No
If yes, how often? _______ Avg. length (days) of travel: _____
Typical wake time: _______________________ Typical bedtime: _________________________
Do you consume alcoholic beverages? (circle one) Yes or No
If yes, what kind and how much? _____________________________ How often? __________
Do you use tobacco products? (circle one) Yes or No
If yes, what kind and how much? _____________________________ How often? __________
Nutrition
What nutrition changes have you made? ________________________________________________
Do you follow a diabetes diet? Yes or No
Do you follow any other diet? Yes or No __________________
Do you take any supplements and what? ________________
Have you had a weight gain or loss of more than 10 pounds in the last 6 months? (circle one)
Yes
or
No
If yes, please explain: ___________________________________________________________________
Texas Health Arlington Memorial Hospital, Diabetes Management Health History & Assessment, Page 2 of 5 October 1, 2010
Have you ever seen a dietitian? Yes or no
How many times a week do you eat foods not prepared at home? _________________________________
Who does the cooking at home? _______________________
Please list any food allergies or intolerances: ___________________________________________________
Current Food Intake (include foods and amounts)
Breakfast: Time:
Snack: Time:
Lunch: Time:
Snack: Time:
Dinner: Time:
Snack time:
Exercise / Activity
Do you exercise on a regular basis? (circle one) Yes or No
If yes, type of exercise _______________________ How often? ____________ How long? _________
Do you have any problems with exercise? (circle one) Yes or No If yes, please explain: _____________
Medication History
Do you take oral diabetes medication? (circle one) Yes or No
If yes, give name, dosage and frequency _______________________________________________
Do you inject insulin? (circle one) Yes or No
If yes: Give name, # units and frequency ________________________________________________
What do you use to inject? (check one)
 A syringe  An insulin pen  An insulin pump
Where do you store your insulin? ________________________________________________
Who fills your syringes? _______________ Who injects your insulin? _________________
What do you do with used syringes? ______________________________________________
Have you ever forgotten to take your diabetic medication(s)? (circle one) Yes
Do you wear or carry diabetic identification? (circle one)
Yes
or
or
No
No
Texas Health Arlington Memorial Hospital, Diabetes Management Health History & Assessment, Page 3 of 5 October 1, 2010
Acute Complications
Have you had low blood sugar? (circle one) Yes
No
or
Have you ever had high blood sugar? (circle one)
Yes
If yes, how often? ________________________
or No
If yes, how often? ___________________
Self Monitoring Blood Glucose
Do you check your blood sugar? (circle one)
Yes
or
No
How often?_______________________________
Describe how you feel with low blood sugar and what actions you take: _______________________________
_________________________________________________________________________________________
Describe how you feel with high blood sugar and what actions you take: ________________________________
Average blood sugar: fasting __________
premeal _______________ postmeal ______________
What do you consider a normal bood sugar? __________________
Which monitor do you use? ___________________ How do you record blood sugar? (log or meter? ___________
Do you ever have difficulty checking your blood sugar? (circle one) Yes or No
If yes, explain: ____________________________________________________________________
Does anyone in your family know how to test your blood sugar? (circle one)
If yes, who? __________________________
Yes
or
No
Spirituality / Stress / Coping

How would you rate your current stress level? (check one)
Low

Medium

High
Reasons for stress: _____________________________
Do you have any difficulty sleeping? (circle one) Yes or No
Avg. number of sleep hours per night: ________
Describe what helps you relax: ____________________________________________________________
What information would help us give you more personalized care? _____________________________________
Do you experience any of the following? (check all that apply)
Is your faith / spirituality a source of help to you at this time?
Are you a part of a community congregation? Yes or No
Is someone hurting you? Yes or No

Anxiety 
Depression 
Mood swings
Yes or No
Do you have any religious concerns? Yes or No
Do you have verbal/physical/emotional/sexual abuse or neglect? Yes or No
Feet
Has your doctor checked your feet? (circle one) Yes or No
If yes, date of last exam: ________________ Describe outcome: ____________________________
Do you check your feet for sores or irritation? (circle one) Yes or No
If yes, how often? ________________ Describe findings: __________________________________
Do experience any of these with your feet? (check all that apply)  Pain  Numbness  Loss of feeling
If any, please explain: _______________________________________________________________
Texas Health Arlington Memorial Hospital, Diabetes Management Health History & Assessment, Page 4 of 5 October 1, 2010
Pregnancy
Are you planning to become pregnant in near future? (circle one)
Yes or No
Are you aware of the effects of pregnancy on diabetes and diabetes on pregnancy? (circle one) Yes
or
No
Education Needs
What areas of diabetes would you like to learn about? (check all that apply)
 Diet
 High blood sugar
 Complications
 What is diabetes
 Low blood sugar
 Sick days

Diabetes medication
 Blood testing
 Pregnancy and diabetes
 Exercise
 Stress
 Insulin
Allergies
Please list any known allergies: __________________________________________________________
Personal Health Goals:
Please complete the following personal health goal information.
1. A personal health goal of mine is to: _______________________________________________________
In order to meet this goal, I will: ___________________________________________________________
How many times/minutes per day? _______________________________ Per week? ______________
2. A personal health goal of mine is to: _______________________________________________________
In order to meet this goal, I will: ___________________________________________________________
How many times/minutes per day? _______________________________ Per week? ______________
Client signature: ___________________________________________ Date: ________________________
Educator signature: ________________________________________ Date: ___________ Time: _______
Educator signature: _______________________________________ Date: ___________ Time: ________
Texas Health Arlington Memorial Hospital, Diabetes Management Health History & Assessment, Page 5 of 5 October 1, 2010