Comprehensive Diabetes Assessment

Patient name *
Gender *
MaleFemale
Date of birth *
Age *
Referring physician *
Name of other person completing the form *
Relationship *
Why are you completing the form? *

SOCIO - ECONOMIC

Racial/ethnic group *
White/CaucasianAfrican American/BlackAmerican IndianAlaskan Native
Language spoken at home *
Transportation *
carbicyclebustaxitrainneed ride from othersother
Number years school completed *
Work status *
employednot employedretireddisabledstudent
Type of job and work hours *
Person(s) living with you *
Person(s) I’d like to bring to diabetes education program at no charge *

EDUCATIONAL NEEDS, LEARNING STYLE, BARRIERS, HEALTH GOALS and SUPPORT

I want to learn about these diabetes self-care topics *
Eating healthyBeing active (exercising)Coping well with having diabetesReducing my risk of diabetes complications with my eyes, skin, feet, kidneys, nerves, heart and other body areas and reducing my risk of very high and low blood sugarMonitoring my sugar and indicators of health, such as blood pressureSolving diabetes problems that can and do occurTaking my medicationsOther
Best ways I learn *
discussionlisteningdoingseeingtouchingreadingvideos/TVcomputer
Learning barriers *
seeinghearingreadingdepressionworry/fearattention deficitlanguagememorylack of confidencecan't sit long enough (fidgety)other
Support resources that may help me make self-care changes and reduce my barriers to these making changes *
books/magazinesvideos/T.V.computers/emails/social networkslive support groupsdoctoreducatorjoining gymco-workersfamilyfriendscaregiverfinancial
My main support in my life *
spouseparent(s)childbrothersisterfriendcaregiverdoctorother
Health goals (clinical outcomes): Improve my: *
fasting blood glucoseBG before lunch/dinnerbedtime BGBG 2 hrs after mealsA1Cblood pressureweightwaist circumferencetotal cholesterolLDL-cholesterolHDL-cholesteroltriglyceridesother
Check the ONE statement that BEST pertains now, at start of program *
I do not plan to make changes in my diabetes care in the next 6 months.I plan to make changes in my diabetes care in the next 6 months.I plan to make changes in my diabetes care in the next month.I have made changes in my diabetes care in the last 6 months.My diabetes has been in good control for more than 6 months.My diabetes has been in good control and then went out of control.

HEALTH CARE UTILIZATION IN PAST 12 MONTHS

Health insurance plan(s) *
Insurance pays for *
glucose meterstripslancetsdiabetes medicationinsulin pumpCGMdiabetes shoeslab testsdoctor visitsdiabetes educationmedical nutrition therapynot sure
Number of:
Hospital stays *
ER visits *
Doctor visits *
Outpatient visits *
Previous diabetes education *
noyes
Dietician visits *
noyes

DIABETES ATTITUDES and BELIEFS

Your knowledge of diabetes and its control is *
excellentvery goodgoodfairpoor
Your confidence in actually being able to control your diabetes is *
excellentvery goodgoodfairpoor
Do you feel that good control is worth it? *
noyesnot sure
Your feelings about having diabetes *
Do you feel that diabetes is serious? *
noyesnot sure

DIABETES HISTORY and CURRENT STATUS

Diabetes diagnosed in year *
Type of diabetes *
type 2type 1gestationalnot sure
Do you carry diabetes identification? *
noyes
Type of identification *
Do you examine your feet? *
noyes
If yes, how often?
dailyweeklymonthlyoccasionally
A1C test results
Date
Value
A1C test results
unknown
I test my blood sugar___times per *
dayweekmonthdon't test
Record results *
yesnosometimes
Brand name of my blood glucose meter *
How old is the meter? *
I test *
fasting/before breakfastbefore lunch/dinnerafter mealsbedtime2-3 a.m.other
Test results
Fasting/before breakfast =
After meals =
Before lunch/dinner =
Bedtime =
2-3 a.m. =
Other =
Had recent episodes of:
high blood sugar comahigh blood sugar (250 or more)low blood sugar (69 or less)ketones in urinediabetic ketoacidosis
Occurs about how many times per month?
Diabetes has caused a problem in these areas of my life: *
family lifesocial activitieswork/schooltravelfinancessports/exercisesexual relationspeace/contentmenteveryday activitiesother
Have a history of: *
eyes/vision problemsnumbness/sensationskidney problemsfeet/toenail problemsteeth/gum problemspoor leg circulationfrequent infectionsheart/artery diseasestrokedry or itchy skinamputationstomach problemsbowel problemsprotein in urineother diabetes problems
Do you get annual flu shot? *
Did you get pneumonia shot? *
Stress level: *
How do you deal with it? *

CULTURAL and RELIGIOUS FACTORS

Special dietary customs, needs, observances (including fasting from food): *
Other cultural or religious practices that may affect your diabetes self-care: *

MEDICAL HISTORY and OTHER MEDICATIONS

Specialists seen in last year for: *
dilated eye exammental healthfoot examkidneysdental check-up and teeth cleaninghearing/earsskinother
My overall health is: *
Have you ever or do you now have any of the following: *
high blood pressurethyroidhigh cholesteroldepressionhigh triglyceridesmental health problemsconstipationpain or fatigue syndromesosteoporosiscancer
If yes to cancer, what kind?
Please list all surgeries and date:

WOMEN ONLY

Number of pregnancies =
Number of children born alive =
Birth weights =
Pregnancy complications:
Did you have gestational diabetes?
Sexual problems:
vaginal drynessloss of libidoother
Plans to get pregnant?
yesnomaybe
Are you pregnant?
yesnomaybe
If yes, pre-pregnancy weight, number of weeks pregnant, due date?

Verification

Please enter any two digits *Example: 12
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