PARTICIPANT SELF-ASSESSMENT OF DIABETES
Date
*
/
Month
/
Day
Year
Date
Patient Demographics
Name
*
First Name
Middle Name / MI
Last Name
Sex
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Person other than patient completing form
Physician Name
Person completing the form
Person(s) I live with
How challenging is it to get to medical/health appointments?
*
Very difficult
Somewhat difficult
Easy
Very Easy
Are you currently employed?
*
Yes
No
Professional Title
Are you deaf or do you have serious difficulty hearing?
*
Yes
No
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
*
Yes
No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
*
Yes
No
Do you have serious difficulty walking or climbing stairs?
*
Yes
No
Do you have difficulty dressing or bathing?
*
Yes
No
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
*
Yes
No
GENERAL DIABETES DEMOGRAPHICS
My overall health:
*
Excellent
Good
Fair
Poor
Don't know
Diabetes diagnosed in yr:
*
Type:
*
Do you have a blood glucose meter?
*
Yes
No
Name of blood glucose meter:
Do you check your blood sugars?
*
Yes
No
Blood sugar range: from
To
If yes, how often
When
Before breakfast
Before bedtime
2 hours after meals
Continuous
Less than 2 hours after meals
Random
Other
What is your target blood glucose range?
Do you carry diabetes identification
*
Yes
No
Can you tell when your blood sugar is too low?
*
Yes
No
What are your symptoms?
What do you do when your sugar is too low?
Can you tell when your blood sugar is too high?
*
Yes
No
What are your symptoms?
What do you do when your sugar is too high?
From whom do you get support for your diabetes?
*
Family
Friends
Coworkers
Health care workers
No one
Other
Other
What is the hardest for you in caring for your diabetes?
*
Knowing what to eat
Getting enough exercise
Taking your medications
Keeping track of your blood sugar
I don't really know how to take care of my diabetes
Knowing what to do when my sugar is too low or too high
Other
Other (please specify)
What are your thoughts and feelings about your diabetes? (e.g. frustrated, angry, guilty)
*
What are you most interested in learning about from these diabetes sessions?
*
CLINICAL
Do you have any difficulty with:
*
Swallowing
Biting or Chewing
Hearing
Seeing
Reading
Speaking
Explain any checked
Weight:
*
Height:
*
Weight Goal:
*
Do you have any stomach troubles?
*
Yes
No
Please explain
Please rate your level of stress (rate between 1-5 with 5 being the highest level of stress)
*
How do you handle stress?
*
Check any of the following test/procedures you have had in the last 12 months:
*
Dilated eye exam
Urine test for protein
Dental exam
Foot exam- self
Foot exam - health care professional
Blood pressure
Cholesterol
HgbA1C
Flu shot
Pneumonia shot
Other
Other
Do you have any of the following (check all that apply):
*
Eye problems
Kidney problems
Dental problems
High blood pressure
Depression
Tingling/numbness/loss of feeling in the feet
High cholesterol
Sexual problems
How many times in the last year did you visit the hospital or the emergency room for reasons related to your diabetes?
LIFESTYLE
Do you drink alcohol?
*
Yes
No
How often do you drink alcohol?
per day
per week
per month
What type of alcohol (check all that apply)?
Beer
White wine
Red wine
Mixed drinks
Liquor
Other
Other
Do you use tobacco?
*
Yes
No
Do you have any diet restrictions?
*
Yes
No
If yes, please explain
What religious or cultural influences effect your lifestyle?
Do you have a meal plan for diabetes?
*
Yes
No
If yes, please describe
How often do you use this meal plan?
Never
Rarely
Sometimes
Usually
Always
Do you do your own food shopping?
*
Yes
No
If not, who does the shopping?
Do you cook your own meals?
*
Yes
No
If not, who does the cooking?
How often do you eat out?
Do you read food labels?
*
Yes
No
Do you exercise regularly?
*
Yes
No
How often do you exercise?
Type
What makes it difficult to exercise?
BEHAVIORAL
Please check if you agree, are neutral, or disagree with the following statements:
I feel good about my general health
*
Agree
Neutral
Disagree
My diabetes interferes with other aspects of my life
*
Agree
Neutral
Disagree
I need to change my eating habits
*
Agree
Neutral
Disagree
I have some control over whether I get diabetes complications
*
Agree
Neutral
Disagree
I struggle to make changes in my life to care for my diabetes
*
Agree
Neutral
Disagree
I need to increase my level of physical activity
*
Agree
Neutral
Disagree
My top 3 barriers to achieving my health goals have been:
1)
2)
3)
Submit
Should be Empty: