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LETTER HEAD/ADDRESSDSME/S Participant Intake FormDate: _________________SECTION 1: DEMOGRAPHIC INFORMATIONLast Name:First Name: DOB:Address:City, State:ZIP:Preferred Contact Number:Other Phone:Cell HomeWorkCell HomeWorkEmail address:Best time to call:(circle all that apply)Before 10a10a-12p12p-3p3p-6p6p-8pSelect your race/ethnicity: American Indian/Alaska Native Asian/Chinese/Japanese/Korean/Pacific Islander Black/African American Hispanic/Chicano/Cuban/Mexican/Puerto Rican/Latino White/Caucasian Middle Eastern Other, please specify: ______________________________________________________What is your language preference?EnglishSpanishOther, please specify: ______________________________________________________How confident are you filling out medical forms by yourself?Extremely Quite a bitSomewhatA little bitNot at allSECTION 2: MEDICAL HISTORYWhat other medical conditions do you have?Allergies Asthma Cardiovascular disease (CVD) Depression Erectile Dysfunction (ED) GoutHypertension (high blood pressure) Migraine headaches Peripheral artery disease (PAD)Anxiety/Panic disordersBenign prostate hyperplasia (BPH) COPD Dialysis Eye problems (glaucoma) Heart attack Insomnia Nerve disorder StrokeArthritis Cancer Chronic pain Dyslipidemia (high cholesterol)GERD (heartburn, acid reflux) Heart surgery Kidney disease Osteoporosis Thyroid diseasePregnant or planning to be pregnant:Other:SECTION 3: DIABETES HISTORY & INFORMATIONWhat type of diabetes do you have?Type 1Type 2GestationalUnsureHow long have you had diabetes? MonthsYearsHave you had previous diabetes education? YesNoIf yes, when? ___________What is the name of your blood glucose meter?Do you know how to use your meter?YesNo Did you bring your blood glucose meter in with you?YesNo Do you have a place to track all your blood glucose valuesYesNo How often has your doctor asked you to check your blood glucose? Every day, once a day in the morning before eating Twice a day, once in the morning and once before supper Three times a day, in the morning, before lunch, before supper Four times a day, in the morning, before lunch, before supper and at bed time Once in the morning and 2 hours AFTER my largest meal each day ? Other: ___________________________________________How often do you actually to check your blood glucose? Every day, once a day in the morning before eating Twice a day, once in the morning and once before supper Three times a day, in the morning, before lunch, before supper Four times a day, in the morning, before lunch, before supper and at bed time Once in the morning and 2 hours AFTER my largest meal each day ? Other: ___________________________________________Please write in how often does your blood glucose drop below 70 mg/dL?Never___/Month___/Week___/DayUnknownDo you carry anything with you to treat a low blood sugar? Please describe how you would treat low blood glucose:Please write in how often is your blood glucose above 180?Never___/Month___/Week___/DayUnknownDo you know what to do with your medications and food if become sick and can’t eat normally? YesNoSECTION 4: SOCIAL INFORMATIONDo you use any form of tobacco products? YesNoIf yes, what type (i.e. cigarettes, chewing tobacco, e-cigarettes, cigars)?If yes, which of the following most accurately describes your current feelings toward quitting tobacco use:I am not thinking about quitting tobacco use any time in the near future. I intend to quit smoking in the next 6 months. I intend to quit smoking in the next 30 days. I have already taken actions to quit tobacco use.During the past month, have you been bothered by feeling down, depressed or hopeless?YesNoDuring the past month, have you had little interest or pleasure in doing things?YesNoDuring the past month, have you had thoughts that you would be better off dead, or of hurting yourselfYesNoSECTION 5: CURRENT MEDICATION USEWhat medications, including prescription, over-the-counter, herbal or nutritional supplements are you currently taking?Medications BY MOUTH (both Diabetes & Non-diabetes)Medication NameDoseHow often do you take it?Any concerns?Do you take aspirin daily? YesNoDo you take vitamins daily? YesNoDo you take any herbal medicines daily? YesNoDo you use any creams/lotions for neuropathic pain (nerve pain)? YesNoDo you use any creams/lotions daily on your feet in general?YesNoAre you currently taking any injectable medication that is not insulin? YesNoIf yes, please list them here: Non- Insulin INJECTABLE Medications (both Diabetes & Non-diabetes)Examples: Victoza?, Trulicity?Medication NameDoseHow often do you take it?Any concerns?Are you currently taking insulin? YesNo (If not, move to next section, please)If yes, please list them here: INSULIN MedicationsDoseInsulin NameInsulin Dose (units)Injection Site(circle all that apply)Time of DoseAny Concerns?1Abdomen, thigh, arm, buttock2Abdomen, thigh, arm, buttock3Abdomen, thigh, arm, buttock4Abdomen, thigh, arm, buttock5Abdomen, thigh, arm, buttock6Abdomen, thigh, arm, buttockAre you on an insulin pump? YesNo SECTION 6: VACCINE HISTORY VaccineReceived? Y/NIf Yes, date received?Influenza (flu)Tdap (tetanus/ whooping cough)Pneumococcal polysaccharidePneumococcal conjugateZoster (Shingles)Hepatitis B (3 doses)SECTION 7: LAB WORK Date of most recent lab work: ___________________________Lab value:Result:My goal (if this has been discussed, please write in. If you’re unsure, please leave blank):A1c___________%___________%Blood Pressure______/______ mmHg______/______ mmHgTotal Cholesterol___________mg/dL___________mg/dLHDL Cholesterol___________mg/dL___________mg/dLLDL Cholesterol___________mg/dL___________mg/dLTriglycerides___________mg/dL___________mg/dLMicroalbuminuria___________mcg/mg___________mcg/mgSECTION 8: DIABETES CHECK-UPSWhen was the last time you saw the dentist?Within the last yearMore than 1 yearI cannot rememberWhen was the last time you saw the eye doctor?Within the last yearMore than 1 yearI cannot rememberWhen was the last time your physician checked your feet?Within the last yearMore than 1 yearI cannot rememberWhen was the last time you had lab work checked?Within the last yearMore than 1 yearI cannot rememberDo you wear diabetic shoes? YesNoSECTION 9: NUTRITIONWhich of the following best describes the way you usually eat?Carb countingCalorie countingWeight/measure foodPlate methodPortion ControlExchange listsAvoid sugarsReduce fatsNo special meal plansOther special meal plan:_____________________________________________Do you drink beverages that are sweetened?YesNoUnsureHow many times per week do you eat out? How many meals do you eat per day? Have you ever worked with a dietician regarding your meal planning? YesNoWhen?SECTION 10: PHYSICAL ACTIVITYWhat type(s) of physical activity do you do?Approximately how much time do you spend on these activities per day?< 10 min.11-30 min.31-60 min.>60 min.NoneHow many days/week do you engage in physical activity of some sort? _____________SECTION 11: INSURANCE INFORMATIONDo you have insurance coverage? YesNo Primary Insurance Company’s Name for PRESCRIPTIONS (i.e. Medicare Part D):Cardholder ID:Group Number:Primary Cardholder Name:Primary Cardholder DOB:Primary Insurance Company’s Name for MEDICAL (i.e. Medicare Part B):Cardholder ID:Group Number: ................
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