Mercy Diabetes Education and Self-Management Program



Mercyhealth Diabetes Education and Self-Management Program

Name: Date of birth: Date:

Occupation: Work hours: Marital status: S M D W

What is your language preference? Spoken: Reading:

Do you have any barriers to learning? ____________________________________________________

How do you learn best? Written material Listening Demonstration Combination

Is there anyone who will help you with your diabetes care? No Yes-Who ________________

Diabetes History:

1. What year were you diagnosed with diabetes?

2. What type of diabetes do you have? Type 1 Type 2 Gestational Pre-diabetes

3. List any family members with diabetes:

4. How would you rate your understanding of diabetes? Good Fair Poor

5. In your own words, what is diabetes?

6. How do you feel about having diabetes?

7. Have you ever been instructed on diabetes or seen a dietitian? No Yes- Date ________

Nutrition:

1. Have you had a change in your weight in the past three months? No Yes- I’ve lost gained ______lbs. Reason(s) ____________________________________________________

2. How many times do you eat per day?__________ Meals? ___________ Snacks? _________

3. List any food allergies or intolerance (s):

4. Do you have any special dietary needs, religious and/or observances? No Yes _________

Medication(s)/Insulin

1. If you take insulin, what kind/dose/time? ____________________________________________

How do you take insulin? syringe insulin pen insulin pump-Model # -

Who gives the injection? Where do you give your insulin?

Where do you keep your insulin? Where do you dispose of your syringes?

2. Do you take pills for your diabetes? No Yes If yes, list what pills you take:

|Drug |Dose/Frequency |Drug |Dose/Frequency |Drug |Dose/Frequency |

| | | | | | |

| | | | | | |

3. Have you ever forgotten to take your diabetes medication? No Yes-What did you do?

_____________________________________________________________________________

4. List all other medications, over the counter meds, nutritional supplements or herbal medicines:

|Drug |Dose/Frequency |Drug |Dose/Frequency |Drug |Dose/Frequency |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

5. Do you have any medication allergies? No Yes-List:

Self-Blood Glucose Monitoring

1. Do you test your blood for sugar? No Yes Name and age of meter

2. How often do you test?____________ Usual results:

3. Do you reuse your lancets? No Yes What do you do with your lancets?

4. Do you test your urine for ketones? No Yes-When do you test?__________Results:

Exercise

1. Do you exercise regularly? No Yes If yes, what type/how long & often?

2. List any problems with exercise:

Acute Complications

1. Have you ever had low blood sugar reaction? No Yes-How did you treat it? _________

2. Do you carry a source of sugar ? No Yes ______________________________________

3. Have you ever been given glucagon? No Yes-Do you have a kit at home? No Yes

4. Does someone you live with know how to give glucagon? I don’t know No Yes

5. Have you ever had high blood sugar? I don’t know No Yes/Date:

If yes, how did you feel & treat it?

History/Chronic medical problems/conditions

1. Do you have any of the following conditions now? (check and explain all that apply)

Eye problems

Heart problems

Kidney problems

Stomach problems

Numbness/tingling/pain

Sexual problems

Other

Medical History

1. When was your last physical examination? Do you wear glasses? No Yes

2. Last eye exam? Were your pupils dilated with drops? ? No Yes

3. How would you describe your general health? Excellent Good Fair Poor

4. Have you noticed any changes in your skin recently? No Yes-Describe _____________

5. Do you check your feet? No Yes- How often? ________________________________

6. When was your last dental checkup? ____________________________________________

7. Do you smoke/chew tobacco? No Yes If yes, how much/often?

8. Do you drink alcohol/beer/wine No Yes If yes, how much/often?

9. Do you use any street/recreational drugs? No Yes If yes, how much/often? __________

10. Have you been hospitalized or gone to the emergency room within the last 6 months? No Yes- Reason (s)-

11. Do you have any stress in your life? No Yes-Please share what kind and how you handle:_______________________________________________________________________

Pregnancy (WOMEN)

1. Are you currently pregnant? No Yes If yes, what is your due date?

2. Are you planning to become pregnant? No Yes –Method of birth control ____________

3. Have you ever been pregnant? No Yes-how many times? Babies > 9 lbs

4. Have you ever had Gestational Diabetes? No Yes-How treated?

Client Signature: Date: ________________________

➢ (Please note on the back of this form is the three day diary for you to write down what you have eaten.)

Educator Signature: Date:

Educator Signature: Date:

Mercyhealth Diabetes Education and Self-Management Program

Food Diary

Please fill in the foods you eat over a 3-day period. Try to include everything to the best of your knowledge.

- Time: approximately what time you had the meal or snack

- Food: What you ate.

- How cooked: baked, fried, broiled, etc.

- Amount: Estimate about how much you ate (example: one, one cup, one fistful)

DAY 1

|DAY1 |Time |Food |How cooked |Amount |

|Breakfast | | | | |

|Lunch | | | | |

|Dinner | | | | |

|Snacks | | | | |

|DAY 2 |Time |Food |How cooked |Amount |

|Breakfast | | | | |

|Lunch | | | | |

|Dinner | | | | |

|Snacks | | | | |

|DAY 3 |Time |Food |How cooked |Amount |

|Breakfast | | | | |

|Lunch | | | | |

|Dinner | | | | |

|Snacks | | | | |

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