Cma Diabetes Education Intake Form (Page 2 of 2) in pdf

Cma Diabetes Education Intake Form Page 2

10. Have you visited with a dietician before? Y N What month/year?______________

11. Has your weight changed by 10 or more pounds, in the last year? Y N Lost or Gained?

12. How many days a week do you eat fast food?__________

13. How would you rate your level of stress?(circle one)

1‐Very Low to None 2‐Low 3‐Neutral 4‐Slightly High 5‐Very High

14. What activities or resources help you when you have stress?

15. Who do you turn to for help or support? Does this person live with you?

Y N

16. Do you have limitations that affect your ability to manage your diabetes?

(Circle all that apply)

Hearing Loss Vision Loss Nerve Pain in Hands or Feet Other___________

17. Are there any cultural considerations that make managing your diabetes difficult? Y N

Please describe.____________________________________________________________

18. Do you have difficulty affording your diabetes medications and diabetes supplies? Y N

19. What do you find the most challenging about living with diabetes?

20. How motivated are you in making changes to maintain your health? (Circle one)

5‐Very 4‐Somewhat 3‐Neutral 2‐Not Really 1‐Not at All

21. What are some of the questions you have about diabetes that you would like to talk about?

Thank you for taking the time to answer these questions. Understanding your

individual needs will help us to come up with the best education plan for you.

Cma Diabetes Education Intake Form Page 2