PLACE LABEL HERE

DIABETES EDUCATION

PATIENT ASSESSMENT and

AMBULATORY SUMMARY

Please fill out this form to help your diabetes educator learn about you.

PATIENT INFORMATION
Name: / Diabetes Diagnosis Date:
Primary Language: English Other: / Occupation:
Education / Last Grade Attended:
LEARNING
Preferred Method: Reading Lecture/Audio Hands On Demonstration Video Group Discussion
What is most important to you to learn about taking care of diabetes?
BLOOD GLUCOSE MONITORING
Do you check your blood glucose? Yes No / What type of meter do you use?
Frequency per day: 1x 2x 3x 4x more than 4x Every Other Day Occasionally Rarely
DIABETES SPECIFIC
Family History of Diabetes? Yes No / Who has Diabetes?
Visit to Emergency Room or Hospital in the last 6 months? Yes No
Reason for visit:
FEMALE SPECIFIC
Did you havediabetes during pregnancy? Yes No / Are you currently pregnant? Yes No
SELF CARE BEHAVIOR
Do you have a history of tobacco use? Yes  No / Do you currently smoke?  Yes  No
How much per day? less than 5  ½ pack  1 pack more than 1 pack  Occasionally
Do you drink alcohol? Yes  No / How much per day? Less than 1 drink  1-2 drinks more than 3 drinks
PHYSICAL ACTIVITY
Do you participate in regular physical activity? Yes  No
What type? / How Often?

*4-16720*FORM 4-16720 REV. 04/2014 Page 1 of 3

PLACE LABEL HERE

DIABETES EDUCATION

PATIENT ASSESSMENT and

AMBULATORY SUMMARY

MEALS AND DINING
Do you have any cultural or religious dietary practices?  Yes  No Please Specify:
List any recent changes in your eating habits:
List any special food considerations in developing a meal plan for you:
Please write out what you eat in a typical day:
Morning (Breakfast) Mid-morning Mid-Day (Lunch)
Time: Time: Time:
Mid-Afternoon Evening (Dinner) Before Bed
Time: Time: Time:
PATIENT SELF-ASSESSMENT
How would you rate your understanding of diabetes? Good Fair  Poor
Feelings about Diabetes: Denial Sadness/Depression Anger Fear Guilt
Overwhelmed/Confused Adaptation Acceptance
How would you rate your overall health?Good Fair Poor / What is a healthy weight for you?
How would you rate your stress level? High Medium  Low
Diabetes Interferes With: Nothing Family/Social Activities Work/School Sports/Exercise
Finances Sexual Relations Travel Other:
Do you carry identification that states you have diabetes? Yes No
How important is your health to you?  Extremely  Somewhat  Only when ill  Not important
MEDICATION/DOSAGE / KNOWN ALLERGIES AND DRUG/FOOD INTERACTIONS
 See Home Medication List /  See Home Medication List
SIGNIFICANT OPERATIVE AND INVASIVE PROCEDURES / Office Use Only
Initials
1.
2.
3.
4.
5.
PROBLEMS/DIAGNOSES/CONDITIONS
Check all that apply and add any not listed. / For Office Use Only
Date Entered / Date Resolved / Initials
1. Skin:(including excessive dryness, itchiness, and slow wound healing)
2. Eyes:(including eye disease and blindness)
3. Nerves:(including nerve disease and neuropathy)
4. Thyroid:(including hyper- and hypothyroidism)
5. Kidneys/Bladder:(including kidney disease)
6. Heart:(including high cholesterol, congestive heart failure, heart attack)
7. Intestines/Digestion:(including chronic diarrhea, constipation, ulcers, and reflux)
8. Groin/Sexual Organs:(including impotence, dryness, and chronic yeast infections)
9. Circulation/Blood Pressure:(including high blood pressure and stroke)
10. Arms/Legs:(including tingling, numbness, and pain)
11. Feet:(including foot ulcer and infection)
12.Emotional illness
13.
14.
15.
16.
17.
18.
19.
20.

______

Date Time SignatureRelationship to patient

For Office Use Only. Reviewed by:

Date Reviewed / TimeReviewed / Name & Title / Initials
Anthropometric Information for Diamed Entry
Weight / Eye Exam Yes/No / BG at office visit
Height / Foot Checks Yes/No / BP at office visit
Contact for outcomes (phone/email)

FORM 4-16720 REV. 04/2014 Page1 of 3