PATIENT QUESTIONNAIRES: DIABETES QUESTIONNAIRE

Size: px
Start display at page:

Download "PATIENT QUESTIONNAIRES: DIABETES QUESTIONNAIRE"

Transcription

1 PATIENT QUESTIONNAIRES: DIABETES QUESTIONNAIRE Use this DiabetesQuestionnaireas a personalized test to help you evaluate how you perceive your diabetes, how you manage your diabetes care, and with your answers, determinethe areas in which you may need help. As you know, there are different kinds of diabetes: Type 1, also called JUVENILE, and Type 2, also called ADULT. There are more types but these are the most common and we will focus on them here. This questionnaire can be brought to your health care professional and show him or her how your symptoms and what you feel have changed from one visit to the next. It is not designed to make a diagnosis of diabetes, or take the place of a professional diagnosis. If you suspect that you have a problem, please consult with your health care professional and /orendocrinologist as soon as possible. QUESTIONS: 1. How old are you? 2. How would you describe your health? Excellent Very Good Good Fair Poor 3. How much do you weigh? 4. How tall are you? 5. Do you know your Body Mass Index? * see below on how to calculate your BMI a. Calculating your own BMI is very easy if you know your height and weight: i. Measure your height in meters (h) and multiply the figure by itself (square). ii. Measure your weight (w) in kilograms and then Divide your weight by your height squared iii. FORMULA: BMI = w/(h x h) 6. Circle the result of your BMI : a. Lower than 25 kg/m2 b kg/m2 c. Higher than 30 kg/m2 7. Have you ever measured your waist circumference in cm (usually at the level of the navel)? Yes No 8. Please measure your waist circumference with a measuring tape, what is it? cm 9. Please circle the category in which it falls: MEN WOMEN Less than 94 cm Less than 80 cm cm cm More than 102 cm More than 88 cm 10. Do you have three meals a day? Yes No 11. Do you snack in between meals? Yes No 12. Are you a picky eater? Yes No

2 13. Has anyone ever taught you about counting carbohydrates? Yes No 14. Do you count carbohydrates? Yes No 15. How often do you eat vegetables, fruit or berries?(in a scale of 0-10 please answer if none=0, if all as recommended =10) a. Breakfast: b. Mid-morning snack: c. Lunch: d. Mid-afternoon snack: e. Dinner: f. After dinner snack: 16. Do you like to add salt to your food? Yes No 17. Do you like salty foods? Yes No 18. Do you like fast food? Yes No 19. Do you like fried foods and fast food restaurants? Yes No 20. Have you ever seen a dietician? Yes No 21. Do you consider yourself to be: ACTIVE or MODERATELY ACTIVE or MODERATELY SEDENTARY or SEDENTARY or VERY SEDENTARY 22. Do you exercise regularly? Yes No 23. Do you usually have daily at least 30 minutes of physical activity at work and/or during leisure time (including normal daily activity)?yes No 24. Do you have limitations to your activity? Yes No What are they? 25. Do you go to the gym? Yes No:How often (circle the days of the week)? M T W Th F S S 26. How long do you stay at the gym? 30 minutes 60 minutes Other a. What percentage of the time is cardiovascular training b. What percentage of the time is weight training c. What percentage of the time is devoted to stretching 27. Have you worked out with a physical trainer? Yes No If YES, When was the last time? 28. Have you ever needed physical therapy? Yes No 29. How good do you sleep? Great Good Not so good Awful 30. Do you snore? Yes No If YES, on a scale of 1-10 how bad would you grade it? 31. Have you ever had a sleep study?yes No 32. If yes, do you use a machine for sleep apnea? Yes No, If YES, what kind? 33. Have you even been told you have a sleep disorder such as restless leg syndrome? Yes No 34. Do you suffer from insomnia? Yes No 35. Do you have any other medical problem? Yes No, If Yes, what?

3 36. Have you ever been told you have High Blood Pressure? Yes No 37. Do you test your blood pressure at home? Yes No, If YES, do you keep a log or a record? Yes No 38. Have you ever had your cholesterol tested? Yes No If YES, How long ago? 39. Do you know your last cholesterol values? Yes No 40. Have you ever been diagnosed with elevated cholesterol? Yes No 41. If you have been diagnosed with elevated cholesterol, are you on treatment? Yes No 42. If YES (prescription for elevated cholesterol), What is it? How long have you been taking it? Months Years 43. Do you have lung disease? Yes No If YES, What? 44. Have you ever had heart disease? Yes No, If YES, what? 45. Have you ever had a heart catheterization? Yes No, If YES, when? 46. Have you ever had a heart attack? Yes No, If YES, when? 47. In the past month, rating 0 as no problem and 10 as having a severe problem please rate the following: a. Discouraged by your health? b. Frustrated with your health problems? c. Fearful of the future of your health and wellbeing? 48. In the past month, rating 0 as no problem and 10 as having a severe problem please rate the following: a. Fatigue: b. Shortness of breath: c. Changes in vision: d. Gain in weight: e. Loss of weight: f. Had a yeast infection: 49. In the past week, rating 0 as no problem and 10 as having a severe problem please rate the following: a. Increased thirst: b. Dry mouth: c. Decreased appetite: d. Nausea or vomiting? e. Abdominal Pain? f. Frequent urination? g. Waking up at night more than three times to urinate: h. Morning Headaches? 50. Have you ever been found to have high blood glucose / blood sugar (For example:in a health examination, during an illness, during pregnancy)?yes No 51. Have any of the members of your immediate family or other relatives been diagnosed with diabetes (type 1 or type 2)?Yes No 52. Do you know what type of diabetes you have? Type 1 Type If you are diabetic, do you own a glucometer? Yes No, If YES, what BRAND is it?

4 54. How old is your glucometer? years or months 55. How often do you test your blood sugar? a. Rarely b. Once Weekly c. Once Daily: In the morning In the evening Before bedtime d. Twice Daily: In the morning and at bedtime Before and 2 hours after a meal -alternating meal times e. Three times a day: Before meals Random times Before and after a meal and another random f. Four times a day: Before meals and at bedtime Before and 2 hours after a meal- twice 56. Have you ever connected your glucometer (download) to a computer at the doctor s office? Yes No 57. Do you know how to download your glucometer at home? Yes No 58. Have you ever heard of Continuous Glucose Monitoring (CGMS)? Yes No 59. Have you ever had a Continuous Glucose Monitoring (CGMS)? Yes No If YES, when? 60. Has anyone ever talked to you about insulin pump technology? Yes No If YES, when? 61. Did you ever wear an Insulin Pump? Yes No If YES, are you still on one? Which one? 62. How long have you used your Insulin Pump? 63. When was the last time you visited your Primary Care Provider? 64. Do you see a Diabetes Specialist or an Endocrinologist? Yes No If YES, when was the last time you had a visit? 65. When was the last time you visited your eye doctor and had your eyes dilated and checked for diabetic retinopathy or any other eye problem such as cataracts? 66. Have you ever been told you have diabetic eye disease? Yes No, If YES, what? 67. If you have eye disease, what treatment have you received? 68. Have you ever visited a podiatrist? Yes No If YES, When was the last time you went? 69. Have you ever been told you have neuropathy? Yes No, If YES, are you taking medication for this problem? 70. When was the last time your kidneys were checked for PROTEIN leakage caused by Diabetes? 71. Have you ever been told you have kidney problems (neuropathy)?? Yes No, If YES are you taking medication for this problem? IF YOU ARE A DIABETIC TYPE 2 AND ARE DEPENDENT ON INSULIN 1. When were you diagnosed with Diabetes Type 2? Year How old were you? 2. How many months or years have you had Diabetes Type 2?

5 3. Have you previously seen an Endocrinologist? Yes No If YES, who was it? 4. What medications for diabetes are you taking? 5. How long do you wait between being diagnosed with diabetes and starting medication? 6. Are you on INSULIN? Yes No If YES, what kind? 7. Are you on blood pressure medications? Yes No If YES, what kind? 8. Do you have any other medical problem? 9. Do you count your carbohydrates? Yes No If YES, How long have you been doing this? 10. How many times a day do you test your blood sugar? IF YOU ARE A DIABETIC TYPE 1 AND/ OR DEPENDENT ON INSULIN 11. When were you diagnosed with Diabetes Type 1? Year How old were you? 12. How many months or years have you had Diabetes Type 1? 13. Have you previously seen an Endocrinologist? Yes No If YES, How long ago? 14. Have you used a Continuous Glucose Monitor (CGMS)? If YES: a. DEXCOM b. MEDTRONICS- ipro or in your Insulin Pump c. Other: 15. What insulin regimen do you use? (circle the answer) a. NPH and Regular b. Mixed Insulin 50/50 or 70/30 c. Intensive Insulin with SHORT acting insulin before meals and LONG acting insulin once or twice a day d. Insulin Pump Therapy 16. How do you calculate your insulin dose? a. Sliding Scale b. Calculation with FORMULA: Write down your formula here: i. Carbohydrate counting and blood sugar goal, If so, what is yours? ii. CARBOHYDRATE TO INSULIN RATIO, If so, what is yours? iii. SENSITIVITY FACTOR, If so, what is yours? c. Insulin pump 17. What kind of SHORT acting insulin are you taking? 18. How do you calculate the amount of short acting insulin needed to take? 19. How long do you wait between injecting the short acting insulin and your meals? 20. What kind of LONG acting insulin are you taking? 21. Do you have a set or fixed dose (amount) of the long acting insulin needed to take? Yes No 22. If YES, How MUCH do you take? At what time do you take it? AM PM Both 23. How long do you wait between injecting the short acting insulin and your meals?

6 24. Do you count your carbohydrates? Yes No If YES, How long have you been doing this? 25. How many times a day do you test? WRITE DOWN ANY QUESTIONS YOU MAY HAVE FOR YOUR HEALTH CARE PROFESSIONAL

Dose Adjustment Retrospective CGMS Guidelines for Patients on Pump Therapy

Dose Adjustment Retrospective CGMS Guidelines for Patients on Pump Therapy Dose Adjustment Retrospective CGMS Guidelines for Patients on Pump Therapy You have been given this set of insulin, dosage adjustment guidelines because you use insulin pump therapy. Pump therapy consists

More information

SAMPLE QUESTIONNAIRE

SAMPLE QUESTIONNAIRE Stanford Patient Education Research Center Stanford University School of Medicine SAMPLE QUESTIONNAIRE DIABETES You may use all or parts of the questionnaire at no charge without permission Stanford Patient

More information

Lifestyle & Diabetes Questionnaire

Lifestyle & Diabetes Questionnaire Please complete this questionnaire. The time you take to provide this information will help your health care team work better for you. General, Medical and Health Information Date: Name: Age: Race: Current

More information

Basics of Blood Sugars

Basics of Blood Sugars PATIENT EDUCATION patienteducation.osumc.edu What is a blood glucose level? A blood glucose level is the amount of glucose (sugar) in your blood. When you take a steroid medicine, your blood sugar can

More information

Hyperglycemia. This reference summary helps you better understand hyperglycemia. It discusses symptoms, causes, treatment and prevention.

Hyperglycemia. This reference summary helps you better understand hyperglycemia. It discusses symptoms, causes, treatment and prevention. Hyperglycemia Introduction Hyperglycemia is high blood sugar. Several factors can cause hyperglycemia in people with diabetes. People who do not have diabetes may develop hyperglycemia during a severe

More information

Women and Heart Disease. What Every Woman Needs to Know.

Women and Heart Disease. What Every Woman Needs to Know. Women and Heart Disease What Every Woman Needs to Know. Women s Heart Program at Saint Francis www.stfranciscare.com/womensheart Women s Heart Program... 860-714-6389 Hoffman Heart and Vascular Institute...

More information

What to Expect During Your Stay at a Sleep Disorders Lab

What to Expect During Your Stay at a Sleep Disorders Lab What to Expect During Your Stay at a Sleep Disorders Lab Information for patients and families Read this information to learn: what a sleep study is what a CPAP titration study is how to prepare what to

More information

As blood sugar levels become more abnormal, additional symptoms may include headaches, blurred vision, and fatigue.

As blood sugar levels become more abnormal, additional symptoms may include headaches, blurred vision, and fatigue. What Is Type 2 Diabetes? Type 2 diabetes strikes people of all ages, and early symptoms are subtle. In fact, about one out of three people with type 2 diabetes don't know they have it. This chronic condition

More information

Q1: Which of these is added to the food label because people sometimes don t eat ENOUGH of this? Cholesterol

Q1: Which of these is added to the food label because people sometimes don t eat ENOUGH of this? Cholesterol Trivia Challenge Q1: Which of these is added to the food label because people sometimes don t eat ENOUGH of this? (C) (D) Fat Calcium Sodium Cholesterol Answer: Calcium Q2: Why do experts recommend losing

More information

DIABETES COMPLICATIONS PROMPT DECK. stack the deck. against diabetes complications. Sponsored by

DIABETES COMPLICATIONS PROMPT DECK. stack the deck. against diabetes complications. Sponsored by DIABETES COMPLICATIONS PROMPT DECK stack the deck against diabetes complications EYE DISEASE KIDNEY DISEASE HEART DISEASE NERVE DAMAGE USING THE CARDS: CATEGORIES OTHER COMPLICATIONS SCENARIOS Q&A DISCUSSION

More information

monitoring blood glucose

monitoring blood glucose monitoring blood glucose monitoring monitoring monitoring monitoring monitoring Blood glucose control is vital for your health. But the only way to tell if your blood glucose is in control is to monitor

More information

Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy

Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy Insulin Dose Adjustment REAL-Time CGMS Guidelines for Subjects on Pump Therapy In addition to using the blood sugar logs to adjust your insulin doses every week, you should also use your continuous glucose

More information

Diabetes Medical Management Plan (DMMP)

Diabetes Medical Management Plan (DMMP) Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff

More information

YMCA of Metro Chicago Diabetes Medical Management Plan (DMMP)

YMCA of Metro Chicago Diabetes Medical Management Plan (DMMP) YMCA of Metro Chicago Diabetes Medical Management Plan (DMMP) of Plan / / Plan Effective s: / / through / / MEMBER INFORMATION PLEASE PRINT First Last of Birth / / of diabetes diagnosis Type 1 Type 2 Other

More information

Blood Glucose Management

Blood Glucose Management Blood Glucose Management What Influences Blood Sugar Levels? There are three main things that influence your blood sugar: Nutrition Exercise Medication What Influences Blood Sugar Levels? NUTRITION 4 Meal

More information

Blood Sugar Testing. Bayer Health Facts

Blood Sugar Testing. Bayer Health Facts Blood Sugar Testing Bayer Health Facts What is Blood Sugar Testing? A blood sugar test tells you how much sugar is in your blood at the moment it is tested. Blood sugar is also called blood glucose. One

More information

Heart Disease, Stroke, Diabetes and Kidney Disease

Heart Disease, Stroke, Diabetes and Kidney Disease Page 1 Fact sheet Heart Disease, Stroke, Diabetes and Kidney Disease Chronic kidney disease (CKD) is called a silent disease as there are often no warning signs. You can lose up to 90 percent of your kidney

More information

Diabetes History Questionnaire

Diabetes History Questionnaire Diabetes History Questionnaire Please answer the following questions to the best of your ability. Allergies: Yes No None known. If yes, to what?,,,, Medical History: Please check any conditions that you

More information

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE The Health Risk Assessment (HRA) questionnaire provides participants with an evaluation of their current health and quality of life. The assessment promotes health

More information

EPCHS Health Center 1401 E Washington St East Peoria IL Phone: Fax:

EPCHS Health Center 1401 E Washington St East Peoria IL Phone: Fax: EPCHS Health Center 1401 E Washington St East Peoria IL 61611 Phone: 309-694-8313 Fax: 309-694-8322 Diabetes Medical Management Plan (DMMP) Date of Plan: This plan is valid for the current school year:

More information

Diabetes-Related High and Low Blood Sugar

Diabetes-Related High and Low Blood Sugar Diabetes-Related High and Low Blood Sugar Topic Overview When you have diabetes, you may have high blood sugar levels (hyperglycemia) or low blood sugar levels (hypoglycemia) from time to time. A cold,

More information

Diabetes Patient Survey

Diabetes Patient Survey Diabetes Patient Survey To help me understand your current medical problem and symptoms, please complete the following questionnaire. In a few words, please describe your condition and how I can help you

More information

An Overview and Guide to Healthy Living with Type 2 Diabetes

An Overview and Guide to Healthy Living with Type 2 Diabetes MEETING YOUR GOALS An Overview and Guide to Healthy Living with Type 2 Diabetes MEETING YOUR GOALS This brochure was designed to help you understand the health goals to live a healthy lifestyle with type

More information

Initial Patient Self-Assessment (Version 2)

Initial Patient Self-Assessment (Version 2) Initial Patient Self-Assessment (Version 2) Demographics: Name: Address: E-mail: Phone Number: Gender: Primary Language: Date of Birth: Occupation: Clerical Skilled Labor Student Retired Homemaker Sales

More information

Family and Friends Guide to Diabetes

Family and Friends Guide to Diabetes Family and Friends Guide to Diabetes If a member of your family or a friend has been diagnosed with diabetes there may be things that you can do to help and important information to be aware of in case

More information

Meeting 1. Glucose Balance Makes a Difference. Welcome! The meeting today is called Glucose Balance Makes a Difference. We will talk about:

Meeting 1. Glucose Balance Makes a Difference. Welcome! The meeting today is called Glucose Balance Makes a Difference. We will talk about: 1-1 Welcome! The meeting today is called Makes a Difference. We will talk about: Why it is important to keep blood glucose (sugar) in balance, What blood glucose numbers mean, Target blood sugar goals

More information

Causes, incidence, and risk factors

Causes, incidence, and risk factors Causes, incidence, and risk factors Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. To understand diabetes,

More information

The complications of Diabetes are a result of: 1. Damage to the large blood vessels

The complications of Diabetes are a result of: 1. Damage to the large blood vessels Preventing Diabetes Complications All people with diabetes Pre diabetes, Type 1 and Type 2 diabetes - are at risk of developing complications. There is no such thing as "MILD DIABETES". Consistently high

More information

There are two ways to review CGM

There are two ways to review CGM CHAPTER 17: HOW TO USE CONTINUOUS GLUCOSE MONITORING (CGM) RESULTS Laurel Messer, RN, BSN There are two ways to review CGM information. One way is to look at the information on the CGM while it is being

More information

Blood Glucose. Staying In Control and On Target. An Omnis Health Guide to monitoring and managing your diabetes

Blood Glucose. Staying In Control and On Target. An Omnis Health Guide to monitoring and managing your diabetes Blood Glucose Staying In Control and On Target An Omnis Health Guide to monitoring and managing your diabetes Know more. Feel better. Live well. If you have diabetes, an essential part of taking care of

More information

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. Diabetes Definition Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood. Causes Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused

More information

UNDERSTANDING BLOOD PRESSURE

UNDERSTANDING BLOOD PRESSURE UNDERSTANDING BLOOD PRESSURE A HANDY GUIDE TO UNDERSTANDING WHAT BLOOD PRESSURE IS, HOW IT AFFECTS YOU, AND HOW TO MEASURE IT AT HOME Authored by the Texas Department of State Health Services Health Promotion

More information

Insulin Treatment Satisfaction Questionnaire (ITSQ)

Insulin Treatment Satisfaction Questionnaire (ITSQ) Insulin Treatment Satisfaction Questionnaire (ITSQ) People who take insulin can have many different experiences with their treatment. Some people who take insulin may find it difficult and burdensome,

More information

Principles for Controlling Your Diabetes for Life

Principles for Controlling Your Diabetes for Life For People with Diabetes 7 Principles for Controlling Your Diabetes for Life A message from UT Extension and the National Diabetes Education Program, jointly sponsored by NIH and CDC. Contents PRINCIPLE

More information

Diabetes Mellitus: Type 1

Diabetes Mellitus: Type 1 Diabetes Mellitus: Type 1 What Is It? Diabetes is a common disorder. It s marked by high blood sugar. Insulin controls how much sugar stays in your blood. The pancreas makes the hormone insulin. People

More information

Blood Pressure Weight BMI. Numbers KNOW YOUR LDL/HDL. Triglycerides. holesterol

Blood Pressure Weight BMI. Numbers KNOW YOUR LDL/HDL. Triglycerides. holesterol Blood Pressure Weight BMI Blood Sugar KNOW YOUR holesterol LDLHDL Numbers Triglycerides Your health truly is the most important thing in your life. Knowing your medical history and getting annual checkups

More information

Congestive Heart Failure

Congestive Heart Failure Congestive Heart Failure Heart failure, also known as congestive heart failure (CHF), means your heart can't pump enough blood to meet your body's needs. Over time, conditions such as narrowed arteries

More information

Diabetes Hypoglycemia/Hyperglycemia Reaction

Diabetes Hypoglycemia/Hyperglycemia Reaction Diabetes Hypoglycemia/Hyperglycemia Reaction Hypoglycemic Reaction (Insulin Shock) A. Hypoglycemic reactions (insulin reactions) should be treated according to current nursing and medical recommendations.

More information

Doing your level best

Doing your level best New blood sugar target goals to consider Doing your level best One of your main goals in treating diabetes is to keep your blood sugar level as close to normal as possible. It takes some effort, but it

More information

Wellness Questionnaire and Assessment

Wellness Questionnaire and Assessment Wellness Questionnaire and Assessment One a scale of 1-10, with 10 being supremely happy, how would you rate your happiness in each of the wellness areas below? Exercise/Movement Physical Health Stress

More information

Hyperglycemia: High blood sugar

Hyperglycemia: High blood sugar Hyperglycemia: High blood sugar Stress Illness Hormones Food Insulin Exercise Target Blood Glucose Range What is hyperglycemia (high blood sugar)? Hyperglycemia or high blood glucose can be caused by:

More information

Monitoring Your Diabetes. Diabetes Monitoring

Monitoring Your Diabetes. Diabetes Monitoring Monitoring Your Diabetes If you have Diabetes, you should be checking your blood glucose at home on a daily basis. But this daily testing does not show your sugar levels over a longer period of time. That

More information

The Family Library. Understanding Diabetes

The Family Library. Understanding Diabetes The Family Library Understanding Diabetes What is Diabetes? Diabetes is caused when the body has a problem in making or using insulin. Insulin is a hormone secreted by the pancreas and is needed for the

More information

Type 1 Diabetes and School

Type 1 Diabetes and School Type 1 Diabetes and School 1 Disclosure The individual presenters are representatives of their respective organizations and are solely responsible for the content of their presentations. The sessions are

More information

Cystic Fibrosis-Related Diabetes (CFRD): Daily Management

Cystic Fibrosis-Related Diabetes (CFRD): Daily Management Cystic Fibrosis-Related Diabetes (CFRD): Daily Management September 20, 2011 This Web cast is supported by an unrestricted educational grant from Genentech, Inc. Antoinette, Moran, MD Professor, Pediatric

More information

You just found out you have diabetes. Now what? If you re like most people, you probably have a lot of questions about living with diabetes.

You just found out you have diabetes. Now what? If you re like most people, you probably have a lot of questions about living with diabetes. Diabetes 101 2 You just found out you have diabetes. Now what? If you re like most people, you probably have a lot of questions about living with diabetes. We will try to answer some of those questions

More information

Monitoring Your Diabetes. Diabetes Monitoring

Monitoring Your Diabetes. Diabetes Monitoring Monitoring Your Diabetes If you have Diabetes, you should be checking your blood glucose at home on a daily basis. But this daily testing does not show your sugar levels over a longer period of time. That

More information

Old Republic Insurance Company of Canada *January Sleep Apnea

Old Republic Insurance Company of Canada *January Sleep Apnea Old Republic Insurance Company of Canada *January 2014 Sleep Apnea Obstructive sleep apnea (OSA) is a condition that causes a blockage of air while a person sleeps. This blockage is caused by soft tissues

More information

Adrenal Insufficiency

Adrenal Insufficiency Adrenal Insufficiency Adrenal insufficiency or AI is a lack of hormones made by the adrenal glands. The adrenal glands are found above each kidney. These glands release hormones called cortisol and aldosterone

More information

LEAD-UP A Lifestyle Education Access for Diabetics: a University Program Texas Woman s University

LEAD-UP A Lifestyle Education Access for Diabetics: a University Program Texas Woman s University LEAD-UP A Lifestyle Education Access for Diabetics: a University Program Texas Woman s University HEALTH AND PHYSICAL ACTIVITY AGREEMENT Before starting a wellness program with Texas Woman s University

More information

Chapter 27 Pregnancy and Diabetes

Chapter 27 Pregnancy and Diabetes Chapter 27 Pregnancy and Diabetes Satish Garg, MD H. Peter Chase, MD INTRODUCTION This book has been used primarily by families of children with diabetes. Because of the increased readership recently by

More information

Healthy at Heart CONTROL. Reduce Your CV Risk. What Is Diabetes? How Can You Control It? Issue 1

Healthy at Heart CONTROL. Reduce Your CV Risk. What Is Diabetes? How Can You Control It? Issue 1 Issue 1 Healthy at Heart Reduce Your CV Risk CONTROL What Is Diabetes? How Can You Control It? Blood sugar targets, tips to help you control your blood sugar, and more inside Healthy at Heart is an educational

More information

TO CONTROL YOUR DIABETES FOR LIFE. Southwest Family Care Alliance

TO CONTROL YOUR DIABETES FOR LIFE. Southwest Family Care Alliance 4 STEPS TO CONTROL YOUR DIABETES FOR LIFE Southwest Family Care Alliance USE YOUR RESOURCES WELL Diabetes is a serious disease. It affects almost every part of the body. That is why a team of people may

More information

Sources. Taking Charge of Your Diabetes. Diabetes Health Log. UnitedHealthcare Insurance Company

Sources. Taking Charge of Your Diabetes. Diabetes Health Log. UnitedHealthcare Insurance Company Diabetes Health Log This chart will help you keep track of your health numbers. Bring it to your next doctor visit. Date Finding Date Finding My Goal Doctor s Exam Date Blood Pressure Total Cholesterol

More information

ADULT DIABETES HISTORY

ADULT DIABETES HISTORY Name: Date Of Birth: Primary/Referring Physician: ADULT DIABETES HISTORY Phone: Phone: E-mail: Cell: When were you diagnosed with diabetes? Marital Status: Single Married Divorced Widowe Separated Cohabitating

More information

Hypoglycemia and Diabetes

Hypoglycemia and Diabetes My Doctor Says I Should Avoid Low Blood Glucose Reactions... How Can I Prevent Them? BD Getting Started Hypoglycemia and Diabetes What You Should Know About Low Blood Glucose Reactions If you are taking

More information

Diabetes Mellitus: Type 1

Diabetes Mellitus: Type 1 Diabetes Mellitus: Type 1 What is type 1 diabetes mellitus? Type 1 diabetes is a disorder that happens when your body produces little or no insulin. The lack of insulin causes the level of sugar in your

More information

Choose an Ascensia blood glucose meter

Choose an Ascensia blood glucose meter H E A L T H F A C T S www.ascensia.ca Choose an Ascensia blood glucose meter AIC testing As you know, keeping your blood glucose levels as close to normal as possible is the key to staying healthy. You

More information

An Overview and Guide to Healthy Living with Type 2 Diabetes

An Overview and Guide to Healthy Living with Type 2 Diabetes MEETING YOUR GOALS An Overview and Guide to Healthy Living with Type 2 Diabetes MEETING YOUR GOALS This brochure was designed to help you understand the health goals to live a healthy lifestyle with type

More information

HOW TO MANAGE ILLNESS WITH TYPE 1 DIABETES PATIENT INFORMATION

HOW TO MANAGE ILLNESS WITH TYPE 1 DIABETES PATIENT INFORMATION HOW TO MANAGE ILLNESS WITH TYPE 1 DIABETES PATIENT INFORMATION What do I do if I become unwell? When you have diabetes you need to take extra care if you become unwell - any illness both minor (headaches,

More information

INITIATING INSULIN PUMP THERAPY

INITIATING INSULIN PUMP THERAPY CHAPTER 3: INITIATING INSULIN PUMP THERAPY H. Peter Chase, MD, Robert Slover, MD and DeAnn Johnson, RN TEAM EVALUATION Ideally, a diabetes care team (referred to as the Team when including the patient/family)

More information

Burlington Neurology & Sleep Clinic, P.L.C.

Burlington Neurology & Sleep Clinic, P.L.C. Burlington Neurology & Sleep Clinic, P.L.C. New Patient Intake Form Dict Done: Date: Name: Patient ID: DOB: _ Age: Height: Weight: Blood pressure: Pulse: Handedness: Right Left _ Ambidextrous Primary Care

More information

Mom! You re drinking a lot lately. Are you all right? I think so. But, you re right. I seem to be thirsty all the time. And, I m tired a lot too.

Mom! You re drinking a lot lately. Are you all right? I think so. But, you re right. I seem to be thirsty all the time. And, I m tired a lot too. Mom! You re drinking a lot lately. Are you all right? I think so. But, you re right. I seem to be thirsty all the time. And, I m tired a lot too. Maybe you should see the doctor? n c Alicia went to the

More information

Lesson 9: Diabetes. Glossary

Lesson 9: Diabetes. Glossary Glossary 1. Carbohydrates: sugars the body needs for energy; found in foods such as rice and bread 2. Diabetes: a disease in which the body either does not produce insulin (type 1) or cannot use insulin

More information

Allergy Information Sheet

Allergy Information Sheet Allergy Information Sheet Student s Name: Grade: Date: Type of Allergies: Check all that apply and list specifics.! Medication:! Food:! Insect Bites/Stings:! Environmental Allergens: Symptoms of Allergy:

More information

Diabetes Medical Management Plan

Diabetes Medical Management Plan 1 Diabetes Medical Management Plan School District: School: School Year: Grade: Student Name: DOB: Provider Name: Phone #: Fax #: Blood Glucose Monitoring at School Blood Glucose Target Range: - mg/dl

More information

type 2 diabetes and you Live Well with Diabetes

type 2 diabetes and you Live Well with Diabetes type 2 diabetes and you Live Well with Diabetes Basic Guidelines for Good Diabetes Care Check your blood sugar regularly At every doctor visit: Review your blood sugar records Blood pressure Weight Foot

More information

Model for Healthy Living Spin the Wheel Game

Model for Healthy Living Spin the Wheel Game Model for Healthy Living Spin the Wheel Game The Church Health Center Model for Healthy Living Game is a great way to enhance communication about all of the wellness components. It can be used at health

More information

Diabetes Health Care Plan Insulin Dosing Guidelines District Nurse Phone: District Nurse Fax:

Diabetes Health Care Plan Insulin Dosing Guidelines District Nurse Phone: District Nurse Fax: Diabetes Health Care Plan Insulin Dosing Guidelines District Nurse Phone: 262-560-2104 District Nurse Fax: 262-560-2106 Date: School Year: School: Grade:,, DOB: was diagnosed with Diabetes Type 1 Type

More information

Understanding Diabetes

Understanding Diabetes Understanding Diabetes What is diabetes? Diabetes is a condition where there is too much glucose (a type of sugar) in your blood. Your blood glucose level is regulated with the help of insulin, a hormone

More information

Nutrition. Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT

Nutrition. Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT 1 Nutrition Type 2 Diabetes: A Growing Challenge in the Healthcare Setting NAME OF STUDENT 2 Type 2 Diabetes: A Growing Challenge in the Healthcare Setting Introduction and background of type 2 diabetes:

More information

Markham Stouffville Hospital

Markham Stouffville Hospital Markham Stouffville Hospital Adult Diabetes Education Frequently Asked Questions What is diabetes? Diabetes is a disease in which blood glucose levels are above normal. Most of the food we eat is turned

More information

Diabetes Self-Management Information and Record Booklet

Diabetes Self-Management Information and Record Booklet Your personal guide... Diabetes Self-Management Information and Record Booklet What you do each day really matters. What is Diabetes? Diabetes is a common, controllable, life-long disease. Diabetes changes

More information

DIABETES MELLITUS. What is diabetes? Types of diabetes. At present there is no cure for diabetes but we can help to prevent and manage it.

DIABETES MELLITUS. What is diabetes? Types of diabetes. At present there is no cure for diabetes but we can help to prevent and manage it. DIABETES MELLITUS THE IDEA Diabetes mellitus is a serious disease, which is becoming increasingly common throughout the world. It is caused when there is too little or no insulin in the body, or when the

More information

Vanderbilt Sports Medicine Diabetes Care Plan

Vanderbilt Sports Medicine Diabetes Care Plan Pre Participation Examination and Clearance Vanderbilt Sports Medicine Diabetes Care Plan History Questionnaire must include: Do you have frequent urination? Do you have excessive thirst? Do you have frequent

More information

Copyright 2008, Nationwide Children's Hospital

Copyright 2008, Nationwide Children's Hospital Diabetes: What Schools Should Know (School Health Plan) Diabetes is a disease in which the body is unable to utilize sugar effectively, resulting in high blood sugar levels. In order to maintain a normal

More information

Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction)

Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction) Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction) 4) activity and 5) other factors such as stress and

More information

Diabetes Fundamentals

Diabetes Fundamentals Diabetes Fundamentals Prevalence of Diabetes in the U.S. Undiagnosed 10.7% of all people 20+ 23.1% of all people 60+ (12.2 million) Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Prevalence

More information

Outline for the Results of the National Health and Nutrition Survey Japan, 2007

Outline for the Results of the National Health and Nutrition Survey Japan, 2007 Outline for the Results of the National Health and Nutrition Survey Japan, 2007 This report was prepared by National Institute of Health and Nutrition as a summary English report of the National Health

More information

DIABETES TYPE II MANAGEMENT

DIABETES TYPE II MANAGEMENT DIABETES TYPE II MANAGEMENT The goal of the Multidisciplinary Team is to provide continuous, supportive, and aggressive care throughout the course of this disease. The consumer is the vital link 1. Diagnosis:

More information

2002 Clinical Practice Guidelines RECOMMENDATIONS FOR CARE OF DIABETES

2002 Clinical Practice Guidelines RECOMMENDATIONS FOR CARE OF DIABETES Type 1 Diabetes- An autoimmune disease in which the body does not produce any insulin, mostly occurring in children and young adults. People with type 1 diabetes must take daily insulin injections to stay

More information

Form Diabetes Care Plan

Form Diabetes Care Plan Form 504.1.5 Diabetes Care Plan Diabetes Care Plan Diabetes Care Plan For: School: Effective Dates: Date of Birth: Grade: Homeroom Teacher: Place photo of student here. Contact Information Parents/Guardians

More information

Type 2 diabetes Definition

Type 2 diabetes Definition Type 2 diabetes Definition Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes. Causes Diabetes

More information

Understanding Diabetes

Understanding Diabetes Understanding Diabetes Diabetes is a disease in which a person s blood glucose (blood sugar) is too high. When you eat, some of the food is broken down into a type of sugar called glucose, which is the

More information

DIABETES GLOSSARY OF TERMS

DIABETES GLOSSARY OF TERMS DIABETES GLOSSARY OF TERMS Diabetes is a common condition, which most people have some understanding of, but when you listen to people talk about it, you may feel as if it has language of its own full

More information

Diabetes Passport. Your Journey to Wellness

Diabetes Passport. Your Journey to Wellness Diabetes Passport Your Journey to Wellness This Diabetes Passport will help you track your health in 4 key areas for people living with diabetes: Body Mass Index Blood Sugar (Blood Glucose) Blood Cholesterol

More information

Diabetes Self Testing Record Logbook. Because diabetes management is a team effort. Your partners in diabetes. I Your journey inspires ours.

Diabetes Self Testing Record Logbook. Because diabetes management is a team effort. Your partners in diabetes. I Your journey inspires ours. Diabetes Self Testing Record Logbook Because diabetes management is a team effort Your partners in diabetes. I Your journey inspires ours. Answers That Matter. The information provided in this logbook

More information

Study Date: Time of Arrival to Sleep Lab:

Study Date: Time of Arrival to Sleep Lab: Pediatric Sleep Study Information Sheet Study Date: Time of Arrival to Sleep Lab: A polysomnogram is a test designed to monitor and evaluate your child s sleep characteristics and physical state during

More information

SLEEP QUESTIONNAIRE. Patient s Name: Age: Height: Weight:

SLEEP QUESTIONNAIRE. Patient s Name: Age: Height: Weight: SLEEP QUESTIONNAIRE Patient s Name: Age: Height: Weight: 1. Please circle any of the sleep problems that relate to you. Number the three problems that are the worst. Sleep Apnea Daytime Fatigue Loud Snoring

More information

DIABETIC EDUCATION MODULE ONE GENERAL OVERVIEW OF TREATMENT AND SAFETY

DIABETIC EDUCATION MODULE ONE GENERAL OVERVIEW OF TREATMENT AND SAFETY DIABETIC EDUCATION MODULE ONE GENERAL OVERVIEW OF TREATMENT AND SAFETY First Edition September 17, 1997 Kevin King R.N., B.S., C.C.R.N. Gregg Kunder R.N., B.S.N., C.C.T.C. 77-120 CHS UCLA Medical Center

More information

DIABETES MEDICAL MANAGEMENT PLAN (DMMP) For Student Requiring Insulin Therapy

DIABETES MEDICAL MANAGEMENT PLAN (DMMP) For Student Requiring Insulin Therapy DIABETES MEDICAL MANAGEMENT PLAN (DMMP) For Student Requiring Insulin Therapy This plan should be completed by the student s parent(s)/guardian(s) and the diabetes health care team. It should be reviewed

More information

Taking Care of your DiabeTes

Taking Care of your DiabeTes Taking Care of your DiabeTes WHaT is DiabeTes? Diabetes is a health problem in which the amount of blood sugar in the body is too high. Here s how it happens: sugar that you eat or drink is digested and

More information

Christina Pasarikovski Student Pharmacist

Christina Pasarikovski Student Pharmacist Diabetes 101 Christina Pasarikovski Student Pharmacist Prevalence of Diabetes in the U.S. Undiagnosed Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Pancreas: How Does It Work? -The main

More information

www.leicestershirediabetes.org.uk Diabetes Care UHL Newly Diagnosed Type 2 Diabetes What Happens Next? A guide for patients and healthcare professionals Introduction The Diabetes Team have produced this

More information

Diabetes Management Program Member Guide

Diabetes Management Program Member Guide Diabetes Management Program Member Guide Important program information Welcome UnitedHealthcare Diabetes Management Program Welcome to the Diabetes Management Program. Our goal is to ensure you are getting

More information

SLEEP HISTORY My main sleep complaint(s) is/are: (give duration of problem also)

SLEEP HISTORY My main sleep complaint(s) is/are: (give duration of problem also) Littleton Adventist Hospital Sleep Disorder Center Patient Questionnaire Please complete this questionnaire as accurately as possible. It will help in the evaluation and interpretation of your sleep study.

More information

TAKING CONTROL. Lower your risk of heart disease and stroke. A Guide for Aboriginal Peoples. Let s put our Hearts into it!

TAKING CONTROL. Lower your risk of heart disease and stroke. A Guide for Aboriginal Peoples. Let s put our Hearts into it! Learn more at the Heart and Stroke Foundation website This site offers a wealth of information and tools to help you and your family prevent and manage heart disease and stroke. At the site, you may find:

More information

Physical Activity Readiness Questionnaire (PAR-Q)

Physical Activity Readiness Questionnaire (PAR-Q) Physical Activity Readiness Questionnaire (PAR-Q) PAR-Q is designed help you help yourself. Many health benefits are associated with regular exercise, and the completion of a PAR-Q is a sensible first

More information

Diabetes FAQs. What is Diabetes? What is insulin?

Diabetes FAQs. What is Diabetes? What is insulin? Diabetes FAQs What is Diabetes? What is insulin? My doctor said I have pre-diabetes or I am borderline diabetic. Do I need to worry? What is hemoglobin A1c? What is the difference between type 1 and type

More information