Diabetes History And Assessment Form Page 2
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1
2P
LEASE PLACE PATIENT LABEL HERE OR FILL OUT
D
H
IABETES
ISTORY AND
Patient Name: ______________________________
A
F
SSESSMENT
ORM
(continued)
MRN: ____________________________________
Have you ever had nutritional counseling?Yes No If yes, how long ago? __________________
Yes No If yes, how often? _____________________
Do you check your feet?
Yes No If yes, what kind and how often? _________
Do you drink alcohol?
Yes No Comments: __________________________
Do you smoke?
Race/Ethnicity
African American/Black
American Indian/Alaskan Native
Caucasian/White
Hispanic/Chicano/Cuban/Mexican/Puerto Rican/Latino
Middle Eastern
Asian/Chinese/Japanese/Korean/Pacific Islander
Education Level
No Formal Education Some High School (7-11)
Some College/Tech
Elementary (1-6)
High School Graduate/GED
College Graduate
When was your last flu shot? ____________________________________________________________
When was the last time you had your eyes checked? __________________________________________
When was the last time you saw a dentist? __________________________________________________
Yes
No
Have you been in the emergency room or hospital in the last 6 months?
If yes, why? ____________________________________________________________________
Yes
No
Are there specific cultural practices that you follow?
If yes please describe:___________________________________________________________________
What are the things that stress you the most in your life? _______________________________________
What helps you relieve your stress?________________________________________________________
Family
Friend
Who can you turn to when you need support?
Over the past 2 weeks, have you often been bothered by:
Yes
No
Feeling down, depressed, or hopeless?
Little interest or pleasure in doing things? Yes
No
What do you hope to learn from this educational program? _____________________________________
Health Goal: A personal health goal of mine is: _____________________________________________
In order to meet this goal, I will: __________________________________________________________
How many times/minutes per day? __________________ Per week? _____________________________
Please list the typical foods and amounts that you eat and drink on a typical day.
Time:
Breakfast: ________________________________________________________Drink ___________________
Time:
Lunch: __________________________________________________________ Drink ___________________
Time:
Dinner: __________________________________________________________Drink ___________________
Snacks: __________________________________________________________Drink ___________________
Do you follow a special diet? Yes No
Height _____ Weight _____ Desired Weight_____
Yes
No
Would you like to be contacted about upcoming Clinical Trials?
Comments: ___________________________________________________________________________
ADA (American Diabetes Association Recognition Program) requires us to collect this information so we may better serve our patients
Diabetes Educator Name: ________________________________________________Date: ___________
W:\Whittier Education\Forms\Assessment Forms Diabetes MNT GDM\Diabetes History and Assessment Form
SWDP
Revised 10/21/2011
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