New Patient Information sheet

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1 New Patient Information sheet In order to best meet your needs during your visit with us and help us provide you with a comprehensive plan your diabetes care, we ask that you please provide the following information about yourself. We ask that you complete this Prior to arrival. If you are not able to do this, we ask that you arrive at least 45 minutes prior to your scheduled visit. Name: Preferred Name: DOB: Male: Female: Address: Home Phone # City: State: Zip.: Cell Phone #: Referred to the Center by (please check one box): Physician Hospital Insurance Plan Friend Family Self Other CONSULTATION INFORMATION Name of Referring Physician: Phone #: IN CASE OF EMERGENCY Name of local friend or relative (not living at same address) Relationship to Patient: Home Phone #: Alt. Phone #: ( ) ( ) Why did you come to the Diabetes Home today? Poorly Controlled Diabetes Testing For Possible Diabetes Insulin Pump Therapy Continuous Glucose Monitoring Diabetes Education Plesase list any problems/concerns that you feel need to be discussed at this appointment: All: Do you currently monitor blood glucose? If yes, name of meter How many times do you test glucose daily? Before Meals After Meals Highest Reading in past 3 months Lowest reading in past 3 months Do you check your feet regularly? If yes, how often? Has your weight changed in the past year? If yes, amount increased If, amount decreased Women: Are you pregnant? If yes, which pregnancy is this for you? If yes, did you have diabetes before this pregnancy? Any plans to become pregnant in the future? If pregnant in the past, how much did your babies weigh? Did you ever have Diabetes in pregnancy? Are you menstruating? Are you sexually active? If yes, please name birth control being used Age of menopause Are you or have you ever used hormones? Diabetes Medications: Name of Insulin Injection/Day Doses or Basal Rates Name of Pills for Diabetes Tablets/Day Doses and Time taken Other Diabetes Medications Medications you have used for diabetes in the past that were not effective or you had side effects from: Form # (8/13)

2 Family History: Any relative with diabetes? Mother Father Grandparent Sister Brother Other Relative Type of diabetes for each? Any thyroid problems in the family? Any male relatives who had a heart attack prior to age 55? Who? Any female relatives who had a heart attack prior to age 65? Who? Personal Information: Marital Status: Married Single Widowed Divorced Significant Other Occupation/Employer: Regular Hobbies: Excercise: Type Times/Week Duration How much stress do you have in your life? Little Moderate High Do you have children? How many? Ages: Other Health Care Providers: ï Name of Primary Care Physician: ï Cardiologist: ï Podiatrist: ï Other Healthcare Providers:

3 General Health History: Date of Most Recent Eye Exam Do you have Retinopathy or Diabetes in the eye? Date of Most Recent Foot Exam Date of Most Recent Dental Exam Have you ever had a cardiac stress test? If yes, when was it last done? Do you smoke now or have you in the past? If ever, how many packs/day? If in the past, when did you quit? Have you ever used any illicit drugs? Do you drink alcohol? If yes, how many times/week? If yes, type of alcohol generally consumed? Never Quit < >10 Have you ever had any surgeries? If yes, please list with dates Have you ever been hospitalized? If yes, please list with dates and reason Ever been treated for high blood pressure? If yes, how high was BP when meds began? Ever been treated for high cholesterol? If yes, how high was cholesterol when meds began? Please list any medications for blood pressure you are currently taking. Name Dosage Times per Day Taken Please list any medications for cholesterol you are currently taking. Name Dosage Times per Day taken Do you have any other medical problems: Urinary Tract Weight Issues Heart Problems Circulatory Problems Eye Problems Depression/Anxiety Numbness or tingling in extremities Changes in bowels Changes in appetite Changes in skin Respiratory Problems Osteoporosis Thyroid Disease Calcium Problems Heart Attack Aortic aneurysm Slow wound healing Sexual problems Muscle, joint pain or weakness Mental Health Problems Ear, nose & throat problems Abdomen pain or bloating Cancer Swelling of extremities Pituitary Gland Problems Adrenal Gland Problems Please describe any health problem(s) you noted above or any not listed: If you are taking any other medications other than those previously listed or any other vitamins/herbal supplements please list them below: Name of Med Dosage Times per Day Taken Name of Med Dosage Times per Day Taken * Please add additional sheet if you have more medications or supplements. Feel free to add a written or typed list of all your medications.

4 Please list any allergies that you have: Are your inmunizations up to date? Have you received a flu shot? If yes, when was last one given? Have you had the pneumovax (pneumonia vaccine?) If yes, when was last one given? DIABETES HISTORY Date of diagnosis? Have you had previous diabetes education? If yes, where and when? What was the last date and result of your Hemoglobin A1C test? What kind of blood glucose meter do you use to test blood sugar? How often do you test your blood sugar? What target range do you try to keep the blood sugars between? How often do you have a low blood sugar? What do you consider a low blood sugar? When is a low blood sugar must likely to occur? What symptoms occur if the blood sugar is low? How do you treat a low blood sugar? Do you have Glucagon? Have you ever had any seizures or unconsious episodes? If yes, include dates and times: How often is the blood sugar over 250mg/dl? When is a high blood sugar most likely to occur? Have there been hospitalization for high blood sugars or diabetic ketoacidosis since diagnosis? If yes, include dates and times of the hospitalization.

5 Insulin Pump Therapy Insulin Pump Therapy please fill out this section if you are using an insulin pump. When was pump therapy started? What is the brand and model of the pump? Is it the short canula? How often do you change the infusion set? Who prescribed it? What type of infusion set is used? Do you ever get infections at the site? If yes how often? Any problem with the infusion set not sticking to the skin? What insertion sites are used? Arm Thigh Hip Abdomen Buttocks Other Do you adjust basal rates? Do you ever use temporary basal rates? Do you use alternate basal patterns? If so, for what event? Do you adjust your bolus settings? Do you use extended (square or dual wave) food boluses? Do you have syringes? Where do you get your pump supplies? Any problems receiving pump supplies? Do you have a plan for injections in the event of pump failure? Do you use injections in addition to what the pump delivers? Sometimes Do you have a prescription for long acting insulin? If yes, what type of insulin? Do you disconnect from the pump more than one hour a day? If yes, why, how long, how often? What plan do you use when disconnected from the pump? At what blood sugar level do you treat low blood glucose? How do you treat low blood glucose? Suspend Quick Carb Temporary Basal Rate Decrease

6 NUTRITION Have you been given a diabetes meal plan? When? By Whom? If yes, what kind? Exchange lists for meal planning Carbohydrate Counting Carb Insulin Ratio is: Consistent Carb ranges for meals and snacks Other (please explain) If you do not have a meal plan, how do you decide what foods to eat? Check all that apply. Eat whatever I want Limit intake of fatty or fried foods Eat until I am full Eat whatever is available Avoid/limit sugar and sweets Eat Out Frequently Limit intake of starchy foods Please describe any changes you would like made in your meal plan: What do you drink? Water how many glasses/day (Check all that apply) Soda how many glasses/day Diet drinks how many glasses/day Sports drinks how many glasses/day Juice how many glasses/day skim 1% 2% Whole Milk how many glasses/day Do you have vitamin Supplements? If yes, please list: What factors make it a challenge to follow a meal plan? (check all that apply) Changes in appetite Activity schedule t hungry Purging Frequent low blood sugars Food not available Disliking food Other Peer or social pressures Too much food in meal plan Cost of food School or work schedule t enough food in meal plan Binging Who usually prepares your meal? I prepare my own meals Spouse Parent or Grandparent Family/friend who lives with you Other person(s) Eat out most of time Self - Image Are you happy with your current weight? Would you like to weigh less or more? Describe: Physician/Provider Signature: Date:

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