Center for Diabetic Wellness

Transcription

1 PERSONAL HISTORY DIABETES INFORMATION CLINICAL DATA Name: Phone: (H) (C) (W) Primary Provider Name: Occ (O) (F) Marital Status: Single Married Divorced Widowed Cohabitating Occupation: Hours per week: Work Shift: 1 st 2 nd 3 rd Work Schedule: MEDICAL HISTORY / FAMILY HISTORY Center for Diabetic Wellness Type of Diabetes: New Onset Uncontrolled Type 1 Type 2 Pre-Diabetes Treatment: Diet-controlled Oral medication Combination therapy Insulin Injections Insulin Pump Diagnosed for how long: Have you had prior diabetes education: No Yes If yes, when? Do you have specific educational needs? No Glycemic Date: FBG (<100 mg/dl) Impaired FG ( mg/dl) Have you been diagnosed with any of the following or do you have a concern? (Please check all that apply) Diagnosed Concern Diagnosed Concern Diagnosed Concern Amputation Heart Disease Liver Disease Arthritis High Blood Pressure Peridontal Disease Asthma or COPD High Cholesterol PVD Bi Polar High Lipids Retinopathy Cancer High Triglycerides Sexual Dysfunction Cataracts Kidney Disease Seizures Glaucoma Chronic Kidney Disease Sleep Apnea CAD/CVD Mental Health Stroke TIA Dental or mouth MI Substance Abuse Depression Neuropathy Thyroid Digestion Problems Numbness/tingling/ Tuberculosis Eating Disorder burning in feet or hands Eye/Vision Problems Erectile Dysfunction Obesity Foot problems Gastroporesis Morbid Obesity Skin conditions Pancreatitis Yes Have you had prior nutritional counseling: No Yes If yes, when? Lipids Date: Total Cholesterol (<200 mg/dl) LDL (<100 mg/dl) HDL (>40-60) Triglycerides (<150 mg/dl) Height Measurement PRE POST A1C (<7%) B/P (<130/80mm/hg) Weight BMI ( ) 1325 N. Highland Avenue Aurora, Illinois Phone Fax Source: American Diabetes Association (ADA), Please list any other medical problems here: Please list any surgeries: Do you have family history of diabetes? Yes No Father Mother Siblings Grandparents Aunts/Uncles 1

2 What pharmacy do you use: Location: Phone: Do you have any food, drug or environmental allergies? No Yes Do you take aspirin? No Yes Please copy information off pill bottles. List diabetes medication first. Name Dose How often Comments Patient did not bring medications today. Instructed to bring to next appointment. Please list names of Complementary and Alternative Therapies: None INSULIN: Skip this section if client does not take insulin Type Units Time of Day How do you take your insulin? syringe insulin pen insulin pump Who fills your insulin syringe? self spouse parent partner Who gives you your insulin injection? self spouse parent partner What injection sites do you use? stomach thighs arms other Do you alternate injection sites? No Yes Where do you keep your insulin? refrigerator bathroom car other Where do you dispose of your syringes? garbage sharps container other Additional Comments: Health Beliefs / Attitudes / Learning Needs How important is your health to you? very important somewhat important not very important How would you describe your general health? Excellent Very Good Good Fair Poor Who makes decisions about your health? self spouse parent partner doctor other How do you feel about having diabetes? angry sad frightened anxious guilty frustrated hopeless lonely ashamed defeated I don t have diabetes other How content do you feel about your life? I feel confident that I know how to control my diabetes I learn best by: lecture discussion demonstration print material audio/visual computers/online role playing games Are you able to read or write: No Yes What level of schooling have you completed: 2

3 Place a check mark in the appropriate box and answer the questions to the right of the yes / no boxes if applicable. Monitoring Yes No Do you monitor your blood glucose (sugar) regularly? Name of monitor Have you experienced low blood glucose readings recently or frequently? (<70 mg/dl or symptoms) Do you need assistance when hypoglycemic? Have you experienced high blood glucose readings recently or frequently? (>250 mg/dl or symptoms) Have you ever been hospitalized due to diabetes complications? (Ketoacidosis, HHS) Do you perform daily foot inspections? Do you get a complete foot exam annually? Do you get your eyes dilated annually? Do you get your teeth examined every 6 months? Physical Activity YES NO If no, please explain: If yes, please elaborate: Frequency: once daily twice daily Other Time of day: fasting before meals after meals bedtime Frequency: daily weekly monthly rarely Time of day: morning afternoon evening overnight after exercise skip a meal Frequency: daily weekly monthly rarely Time of day: morning afternoon evening overnight Are you currently exercising? (4 or more times a week) Type of exercise Times per week Length of time Do you have any restrictions? Are you interested in becoming more physically active? Do you have a sedentary lifestyle/job? Cultural / Financial YES NO Do you have any cultural or religious practices involving foods, eating habits or fasting? Do you have any financial concerns or lack of health insurance? Psychosocial YES NO Do you drink alcohol? Do you use tobacco? Former tobacco user Duration: Quit date: Have you had a significant change in life events (marriage, divorce, illness, death of family member, new home or change in employment) in the last 12 months Please rate stress in your life on a 0 (no stress) to 10 (high stress) scale: If no, please explain: Please explain: Please explain: If yes, check type and include amount per week: Beer Wine Liquor Amt/Wk If yes, indicate type and amount per day: Cigarettes Pipe Cigar # Packs/day #/day #/day Please describe: Mark source(s) of your stress? Work Unemployment Family Health Finances other What do you do to handle stress in your life? 3

4 Family Support and Support Systems YES NO Do you have a significant other, family member, friend or relative with whom you can discuss personal problems and concerns and who could support you in managing your diabetes? Do you have a support person that will be attending your appointments with you? Relationship: Name: Relationship: Who helps you with your diabetes care at home? spouse partner parent daughter/son friend other no one Because diabetes self-care management can take a toll on your emotions and stress level, we ask all our clients the following: During the past week, have you been bothered by feeling down, depressed or hopeless? No Yes During the past week, have you had little interest or pleasure in doing things? CESD Score No Yes Nutrition YES NO Do you currently follow any special diet? Do you have any dietary restrictions? Do you take vitamins, minerals, herbs or any other food/nutritional supplement? Do you do the shopping and/or cooking? Do you eat meals away from home? Do you often eat high fat foods such as pizza, sausage, bacon, gravy, chips, fried foods, butter, cheese, salad dressings, sour cream? Do you often eat high sodium foods such as frozen meals, canned soups or vegetables, instant soups, deli meats, salt? Do you often eat high sugar foods such as desserts, cookies, ice cream, pastry, candy, or sweet breads? If yes, check type: Low Cholesterol Low Sodium calorie counting Carb Counting Low Fat Exchange Label Reading Low Protein Other If yes, please list: If No, indicate who does it: Shopping Cooking How many people in your household? If yes, check which one(s) and number of times per week: Breakfast Lunch Dinner times/wk times/wk times/wk Do you often drink beverages high in sugar such as energy drinks, fruit juice, soda, sports drinks, yogurt drinks, or flavored milks? How many times a day do you eat? What are some of the foods you eat the most? What are some of the foods you avoid? (Please explain) Indicate your usual schedule (Write time of day for each item listed.) Time you get up Time you eat breakfast Time you begin work / school Time you eat lunch Time you get off work Time you eat dinner Bedtime Notes: 4

5 For Educator s Use Only EDUCATOR S ASSESSMENT Barriers to Learning None Language (LEP) Inability to read Visual Physical disabilities Work Schedule Hearing Child care Transportation Comprehension Emotional Problems Financial Memory Recall Special Needs Other: Age Unique Patient Needs: Education Readiness Pre-contemplation (Aware of condition) Contemplation (Thinking about making changes) Preparation Stage (Makes plans for change) Action Stage (Takes active steps towards change) Education Plan Comprehensive DSME Group Individual English Spanish Morning Evening DSME (Select Topic) Disease Process Monitoring Nutrition Medications Problem Solving Acute complications Physical Activity Long Term Complications Psychosocial Adjustment Insulin Instruction only Modified Plan: Date & Plan: Date & Plan: Referrals / Consults Registered Dietitian Ophthalmology (self pay) Smoking cessation Support Group Optometry (self pay) Financial Counselor Endocrine (self pay) Community Resources: MANAGEMENT PLAN Monitoring Plan Goals and Outcomes Source: American Diabetes Association, 2010 & American Association of Clinical Endocrinologist, 2010 Frequency: Fasting Pre meals: B L D 1 hr PP: B L D Target Ranges: mg/dl <110 mg/dl Other mg/dl <110 mg/dl Other Intermediate Outcomes: Performs daily SMBG within target ranges / record results Follows meal plan as recommended Takes medications as prescribed Complete DSME Program 2 hr PP: B L D <180 mg/dl <140 mg/dl Other Post -Intermediate Outcome: A1C less than 7% A1C less than 6.5% Bedtime Bedtime: mg/dl ADDENDUM: Print Name (Conducted By) Signature Title Date Print Name (Reviewed By) Signature Title Date 5