Form Jmc0191 - Patient Initial Assessment-Diabetes Form
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2PATIENT INITIAL ASSESSMENT-DIABETES
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone: Home
(___J
Work:
(___J _ _ _ _ _ _ _
Mobile:
(___J_ - - - - - -
Date of Birth: __J__J,_Age: _ _ Gender:_F_M Weight
Height
Weight Goal _ _ _
Ethnic Background: White/Caucasian_BlackiA·A _Hispanic_
Native American_
Middle-eastern_
PLEASE ANSWER THE FOLLOWING QUESTIONS:
1.
Marital Status: Single_ Married_ Divorced_ Widowed_ Significant other __
Number in household: __ How are they related to y o u ? - - - - - - - - - - - - - - - -
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get support for my diabetes from: Family _ _ Co-workers __ Health care providers __ Support Group _ _
No one__
other
2. Currently employed? N _ _ Y _ _ Occupation?
Work hrs: _ _ _ _ _ _
Primary Language: English
Other
Highest grade completed? _ _ _ _ _ _
Need Assistance with: Visual _ _ Hearing __ Reading _ _ Physical Limitation:
Other: _ _ _ _ _
3. What type of diabetes do you have? Type
1 __
Type 2 __ Pre-diabetes __ GDM__ Don1 Know __
Year/Age of Diabetes Diagnoses:
Relatives with d i a b e t e s : - - - - - - - - - - -
What is diabetes? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Previous diabetes educatiOn: N_ Y __
4.
Do you take diabetes medications? N __ y _ _ which one/s: Diabetes pills __ Insulin injections __
Byetta injections__
Symlin injections__
Combination of pills and injections. _ _ _ _
Have you forgotten to take your diabetes medications?: N __ Y __ What do you do? _ _ _ _ _ _ _ _ _
If you take insulin: Where do you store it?
Inject it?
Dispose of it? _ _
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 __ 2 or more/day_
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or more/Week_ Other _ _ _ _ _ _
When: Before breakfast__
2 hours after meals__
Before bedtime __ Other _ _ _ _ _ _ _ _ _
Results: before meal
after meal
bedtime
Do you keep a record: N __ Y _ _
6.
How often have you had a low or high blood sugar in the last 3 months:
Low blood sugar: how often?: _ _ _ _ _ _ _ Time of day _ _ _ _ _ _ At what number? _ _ _ _
Symptoms?
Treatment? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Do you have a glucagon kit? N_ Y_ If you've used it, When? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
High blood sugar: how often?
Time of day _ _ _ _ _ _ At what number? _ _ _ _
Symptoms?
Treatment? _ _ _ _ _ _ _ _ _ _ _
Wear a medical ID? N __ Y__
Test for ketones? N_Y __ When? _ _ _ _ _ _ _ _ _ _ _ _
7.
Do you have?: eye problems __ . kidney problems _ _ numbness/tingling/loss of feeling in feet_ heart
disease __
8. Do you smoke: f\L_Y_ What ? _ _ _ _ _ _ How many? _ _ _ _ _ _ How long? _ _ _ _ _
Do you drink alcohol? N_ Y_Type:
How many _ _ x per week or month
Caffeine N_ Y_ What? _ _ _ _ _ _ _ _ _ How much? _ _ _ _ _ _ _ _ _ _ _ _ _ _
Do you exercise regularly? N_ Y __ Type: _ _ _ _ _ _ _ _ _ How Often: _ _ _ _ _ _ _ _ _
My exercise routine is: easy
moderately
intense. _ _ _ _ very intense _ _ _ _ _ _
Problems with exercise:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
9. Your medical conditions: High blood pressure_ High Cholesterol_ High triglycerides __ Allergies'----
dental problems_ sexual problems_ depression_ Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1111111111111111111111111
2PA
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Form#JMC0191Rev7/12,10/13, 12/14
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Parent category: Business