Meridan Health Diabetes Management Program Needs Assessment
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3MERIDIAN HEALTH • RMC
DIABETES MANAGEMENT PROGRAM
NEEDS ASSESSMENT
RDM-002X (7-10) PAGE 1 OF 3
*AS7701*
DATE__________________________
INPATIENT
OuTPATIENT
GESTATIONAL
hOME cARE
PEDI
Name: _____________________________________________________________ Phone (
) ______________________________
Address:________________________________________________________________________________________________________
Physician Responsible for Diabetes Management: _______________________________________________________________________
Physician Responsible for Care in Hospital: ____________________________________________________________________________
TYPE OF DIABETES
Type 1
Gestational, if so
Due Date __________________
¨
Type 2
Using Insulin
Oral Agents
Diet and Exercise Only
GENERAL INFORMATION
When was diabetes diagnosed:
Date _____________________________
Birthdate: ________________________ Sex:______________________________ Ethnic Group: ________________________________
Occupation:_________________________________________________________
Work hours:_________________________________________________________
Highest level of education achieved: _____________________________________
Potential barriers to learning?
visual
hearing
language
literacy
physical
emotional
cultural and religious
motivation
cognitive
financial
other ________________________________________
Are you satisfied with your diabetes control?
Yes
No
Any previous diabetes education?
Yes
No When_________________ Where______________________________________
Describe type of education _________________________________________________________________________________________
RELATIvES wITh DIABETES
LIvING ARRANGEMENTS
Parent(s) - (M, F)
Alone
Grandparent(s)
With Family/Ages _________________
Identical Twin
Other
Siblings
Identified Support Person for Instruction?
Yes
No
Name: _________________________________________________________ Relationship: ____________________________________
Self Rated Health 1 - 5 (1-poor; 5-excellent)____________________________________________________________________________
Coping Strategies/Current Major Stress: _______________________________________________________________________________
ExERcISE:
TOBAccO uSE:
ALcOhOL uSE:
Type:____________________
Never
Never
Frequency & Duration:____________________
Quit (year____________)
Number/Week ____________
______min.______days/week
Packs/Day____________
DIABETES MEDIcATION:
Insulin units
N/
R/humalog
L/
70/30
50/50
Insulin Pump
AM
_________
________
________
________
________
________
Lunch
_________
________
________
________
________
________
Dinner
_________
________
________
________
________
________
Bedtime
_________
________
________
________
________
________
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