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DIABETES QUESTIONNAIREPatient Name: ______________________________ Date: ____________________1. When were you diagnosed as having diabetes: ____________________________ Weight at the time: ___________________________________________________ What symptoms did you have: __________________________________________ ___________________________________________________________________2. What treatment did you receive initially: __________________________________ ___________________________________________________________________3. Describe any changes since: Year: _____________ Change: _______________________________________ Year: _____________ Change: _______________________________________ Year: _____________ Change: _______________________________________4. How is your diabetes now being treated: Name of medication or insulin: _________________________________________ Dosage: __________________________________________________________5. How do you monitor your sugar: ________________________________________ How often: _________________________________________________________ Average results: ____________________________________________________6. Describe the diet you were given (calorie intake, salt restriction, protein restriction, Meals, snacks) and how well you were able to maintain it: ____________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________7. Describe any exercise you do on a regular basis: __________________________ __________________________________________________________________8. On a scale of 1 to 10, what level of physical activity is required by your job: ______9. What is your usual daily schedule (include time of diabetic medication, meals, Snacks, exercise, work, etc): __________________________________________ __________________________________________________________________ __________________________________________________________________ How often does this schedule vary significantly: ___________________________ Describe variance: __________________________________________________10. List and describe any hospitalizations due to diabetes: _______________________ ___________________________________________________________________ ___________________________________________________________________11. Describe any previous diabetes education you have had: ____________________ ___________________________________________________________________ ___________________________________________________________________12. Are you familiar with the following topics: Yes/No Any Questions Administering Insulin _______ _______________________________ Ketones _______ _______________________________ Home Glucose Monitoring _______ ______________________________ Sick Day Management _______ _______________________________ Complication of Diabetes _______ _______________________________ Foot Care _______ _______________________________13. What concerns or feelings do you have: __________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________14. Have you ever had any of the following problems (circle all that apply):PROBLEMDESCRIPTIONExcessive thirstWaking up at night to urinateCraving for sugarBeing overweightChange in weightLow blood sugarHeadachesNightmaresNight sweatsTingling in hands/feetNumbness in hands/feetBurning pain in hands/feetBlurred visionRetinal surgeryFloaters/splotches in eyesKidney diseaseSwelling of legsHigh blood pressureHeart failure/heart attackSlow healingChronic rashYeast infectionsBabies over 9 lbsSexual problemsNausea after eatingDiarrhea ................
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