Patient Initial Assessment-Diabetes Education Form

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PATIENT INITIAL ASSESSMENT-DIABETES
Name _____________________________________________________
Date_________________________
Address______________________________________________________________________________________
Phone: Home (_____) _______________ Work: (_____) __________________ Mobile: (_____) _______________
Date of Birth ___/___/___ Age_____ Gender: F__ M__ Weight_________ Height________ Goal Weight _______
Ethnic Background: White/Caucasian___
Black/A-A ___ Hispanic ___ Native American___
Middle-Eastern___
Please answer the following questions:
Marital Status: Single___ Married___ Divorced___ Widowed___ Significant other____
1.
Number in household: ____ Relation to you ________________________________________
You receive support from (check all that apply): Family ___ Co-worker(s) ___ Healthcare provider(s) ___
Support Group ___ No one___
Currently employed: N___ Y___ Occupation ___________________________ Work hours_________________
2.
Primary Language: English____ Spanish___ Other ____________________
Highest grade completed ________________
Type of assistance needed (check all that apply):
Visual___ Hearing___ Reading___
Physical Limitation___ Other _____________
3.
Type of diabetes:
Type 1____ Type 2____ Pre-diabetes____ GDM____ Don’t Know____
Year/Age of Diabetes Diagnoses_______/__________ Relatives with diabetes _________________________
What is diabetes? __________________________________________ Previous diabetes education: N___ Y___
4.
Diabetes medications taken (check all that apply):
Diabetes pills ___ Insulin injections ___
Byetta injections___
Symlin injections___
Combination of pills and injections___ None___
Have you ever forgotten to take your diabetes medications? N___ Y ___
If so, what do you do? _________________________________________________________________________
If you take insulin:
Where do you store it? __________________ Injection site ______________________
Disposal site/method _____________ Who gives injection? _______________________
Method:
Syringe___ Insulin pen___ Insulin pump___
Do you reuse syringes? N___ Y___
Do you have a sliding scale? N___ Y___ (provide copy)
5.
Do you check your blood sugars? N___ Y___ Frequency (times per day/week) _________________________
When:
Before breakfast___
2 hours after meals___ Before bedtime___
Other_______________________
Results:
Morning_____ Noon_____ Evening _____ Bedtime_____ Do you keep a record? N___ Y___
6.
Please provide information on your abnormal blood sugar levels within the last 3 months:
Low blood sugar:
Frequency_________________ Time of day _________ Blood Sugar Level ___________
Symptoms _________________________Treatment _____________________________
Do you have a glucagon kit? N___ Y___ If yes, when do you use it? ________________
High blood sugar:
Frequency_________________ Time of day _________ Blood Sugar Level ___________
Symptoms _________________________Treatment _____________________________
Do you wear a medical ID? N___ Y___
Do you test for ketones? N___Y ___ Frequency___________________

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