Diabetes History And Assessment Form

ADVERTISEMENT

P
LEASE PLACE PATIENT LABEL HERE OR FILL OUT
Patient Name: ______________________________
MRN: ____________________________________
Scripps Whittier Institute Main Line: (858) 626-5672/ FAX 858-626-7111
Rancho Bernardo (858) 605-7369/ FAX 858-605-7272
Vista (760) 806-5863/ FAX (760) 806-5429
D
H
A
F
IABETES
ISTORY AND
SSESSMENT
ORM
Diabetes History
New Diagnosis: Yes
How many years have you had diabetes? ___________________
Who in your family has/had diabetes? ______________________________________________
Type 1
Type 2
Don’t know
What type of diabetes do you have?
Check if you have any of the following medical conditions:
High blood pressure
High cholesterol
Heart attack
Stroke
Numbness/tingling in your hands or feet
Sexual problems
 Depression
Kidney problems
Stomach problems
Cataracts
Glaucoma
 GDM
 Sleep Apnea Please list other medical conditions you have: _______________________
Check if anyone in your family has or had any of the following conditions:
High blood pressure
High cholesterol
Heart attack
Stroke
List all medications you take. Please include vitamins/supplements:
D
T
D
T
N
M
OSE
IME
N
M
OSE
IME
AME OF
EDICINE
AME OF
EDICINE
T
T
AKEN
AKEN
Are you allergic to any medication? _________________
 Food______________________
Yes
No
Do you check your blood sugar?
If yes, how often? _______________________
Name of blood glucose meter
Usual results: ______________________________
: __________________
Last A1c result: _______________Date: _________ Do you get low blood sugar? No
Yes
If Yes what time/s of day/night? ______________________________________________________
Do you exercise? Yes No If yes, what do you do? ______________ How often? __________
If no, list reason or problems that prevent you from exercising: _______________________________
(Turn Over Please To Continue)
W:\Whittier Education\Forms\Assessment Forms Diabetes MNT GDM\Diabetes History and Assessment Form
SWDP
Revised 10/21/2011

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2