Diabetes Self Assessment Form

General Information

0% Complete
Medical History

0% Complete
Diabetes History

0% Complete
Goals

0% Complete
Daily Food Choices

0% Complete

IMPORTANT: All fields with and asterisk * are required.

First Name*:

Last Name*:

Date of Birth*:

Preferred Name:

Occupation:

Email Address

Have you been diagnosed with any of the following? (Check all that apply)

High blood pressure

Heart disease

Stroke

Stomach/Bowel issues

Kidney problems

Foot problems

Depression

Numbness & pain in hands/feet

Eye problems

High cholesterol

Other

Do you have any physical limitations? (Check all that apply)

Hearing

Vision

Physical

Other

How often do you use tobacco products?

Every day

Some days

Quit

Never

How often do you drink alcohol?

Every Day

Several days per week

Once a week

Less than once a week

A few times a year

Never

How often do you have an A1C test?

How often do you check your blood sugar?

How often do you exercise?

How often do you check your feet?

How often do you see your medical provider?

How often do you wear medical ID?

When was the last time you had an eye exam?

When was the last time you went to the dentist?

When was the last time you had a foot exam?

When was the last time you had a pneumonia vaccine?

When was the last time you had the flu vaccine?

When was the last time you had the hepatitis B vaccine?

Have you previously seen a dietitian or diabetes educator?

Yes

Please tell us when:

Date of diabetes diagnosis:

Type of diabetes:

Type 1

Type 2

Other

Which other diabetes type?

Were you in the hospital in the last year because of diabetes?

Yes

Have you had emergency care in the last year because of diabetes?

Yes

How many days of work in the last year have you lost because of diabetes?

What is causing you the most concern about caring for your diabetes currently?

Do you have any spiritual or cultural beliefs we should know about to help us plan for your care?

Yes

What would you like us to do during your visit to address your concern?

I would like answers to the following questions at this visit:

What is one thing about your diabetes that drives you crazy?

What do you see as your individual strengths to help you deal with your diabetes?

How ready are you to make healthy changes in your life?

Not ready

Somewhat ready

Neutral

Ready

Already changing

How confident are you filling out medical forms by yourself?

Extremely

Quite a bit

Somewhat

A little

Not at all

I would like help with the following (Select all that apply):

Increasing my understanding of diabetes

Planning meals

Increasing my understanding of how food affects my diabetes

Eating out, grocery shopping, reading food labels

Increasing activity levels

Keeping my blood sugar in a safe range during excercise

Monitoring my blood sugar

Using blood glucose results to improve control

Developing a plan to take my medicine as prescribed

Increasing my ability to give myself injections

Increasing my knowledge of herbs and supplements

Preventing/treating high blood sugars

Preventing/treating low blood sugars

Managing diabetes when I am sick

Getting support from family/friends

Improving my ability to manage stress and/or emotions

Changing my skin/foot care routine to reduce risk of complications

Ensuring I am getting proper medical care such as eye, dental, & doctor visits

Quitting smoking

What method of meal planning (if any) are you currently using?

Please fill in times and examples of meals or snacks eaten, including beverages throughout a typical day in the table below:

Typical Day	Time	Meal/Snack
I awake:
Breakfast:
Morning snack:
Lunch:
Afternoon snack:
Evening meal:
Evening snack:
Bed time: