Diabetes Questionnaire

1740 St. Julian Place, Columbia, SC 29204
Phone: 803-256-3534 Fax: 803-254-7032
Diabetes History
Date

MonthDayYear
Date
Patient Name*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age of Diagnosis*
When did you start insulin?
What is your biggest concern related to your diabetes?

Complications related to DM*

	Yes	No
Low blood sugars
Diabetic ketoacidosis
Numbness/tingling
Eye damage
Kidney damage
Nonhealing wound

How many times per day do you check your sugar level?*
How many times per week do you exercise?*
What type of exercise do you like?*
When was your last diabetes education?*
Do you have someone in your home that can help you in case you have a low blood sugar?*
Current diabetes medications:
Past diabetes medications and why they were stopped:
Cardiologist
Last Appointment

MonthDayYear
Date
Podiatrist
Last Appointment

MonthDayYear
Date
Nephrologist
Last Appointment

MonthDayYear
Date
Ophthalmologist
Last Appointment

MonthDayYear
Date
Past Medical History

Do you have any of the following:*

	Yes	No
High blood pressure
Diabetes
High cholesterol
Heart attack or stroke
Congestive heart failure
Sleep apnea
Heart disease
Seizures
Kidney disease
Gallstones
Kidney stones
Pancreatitis
Peptic ulcer disease
Thyroid disease
Thyroid cancer
Prostate cancer
Other cancers
Low testosterone
Chronic steroid use
COPD/asthma
Anemia
Menopause
Psychiatric illness
Joint replacements
Osteoporosis
Bone fractures
Rheumatologic disease

Other Medical Conditions Not Listed
Prior Surgeries
Do you have any drug allergies?*

YesNo
If so, please list drug allergies

	Yes	No	If yes, how much?
Do you smoke?
Do you drink?
Do you use recreational drugs?

What is your occupation?*
Are you?*

MarriedWidow(er)SingleDivorced
Family History

Has anyone in your immediate family (only parents, siblings, children) had:*

	Yes	No
High blood pressure
Diabetes
High cholesterol
Heart attack or stroke
Heart failure
Prostate cancer
Calcium disorders
Psychiatric illness
Thyroid cancer
Other thyroid disease
Pituitary problems
Kidney disease

Other medical conditions not listed:
Review of Systems

Check any symptoms you have:

	General
Fever/chills
Weight loss
Weight gain
Night sweats
Weakness/fatigue

	Eyes
Blurry vision
Double vision
Decreased peripheral vision
Eye pain
Dry eyes

	Endocrine
Cold intolerance
Heat intolerance
Excessive thirst
Excessive urination
Excessive sweating
Flushing
Tremulousness
Changes in body hair

	Ears/Nose/Throat
Noticeable swelling in neck
Hearing loss
Ear pain
Ringing in ears
Vertigo
Nasal congestion
Loss of sense of smell
Hoarse voice

	Skin
Rash/purple or red spots/pigment
Fingers/toes turn colors in the cold
Nail problems
Dry skin
Skin ulcers

	Musculoskeletal
Painful joints
Muscle pain
Back pain

Check any symptoms you have:

	Neurologic
Migraines
Headaches
Numbness/tingling
Muscle weakness
Seizures
Muscle cramps
Difficulty thinking or remembering

Check any symptoms you have:

	Mouth
Sores in mouth
Dry mouth
Dental problems
Loss of taste
Difficulty swallowing

	Scalp/Head
Hair loss
Scalp tenderness
Headache

	Allergy
Frequent sneezing
Seasonal allergies

	Respiratory
Shortness of breath
Cough
Wheezing
Chest pain with breathing

	Blood/Lymph
Easy bruising
Enlarged lymph nodes

	Gastrointestinal
Nausea/Vomiting
Constipation/diarrhea
Hemorrhoids
Change in appetite

	Psychological
Anxiety
Depression
Difficulty sleeping
High stress

	Genitourinary
Irregular menses
Hot flashes
Blood in urine
Decreased urine stream
Prostate problems
Frequent urinary tract infections
Decreased sexual desire

	Heart
Chest pain
Stabbing chest pain/pericarditis
Irregular or rapid heart rate
Lightheadedness/passing out
Sleep on more than 2 pillows due to shortness of breath
Leg swelling

	Breasts
Lumps
Pain
Discharge

I certify that my answers are true and complete to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: