DAFNE Data Collection: Full Baseline

Transcription

1 Type of DAFNE course attended? Standard 1 week 5 week Pump Number of course days attended? days (Range: 1 5 days) Please record the method of data collection (more than one can be selected where necessary): Face to Face Telephone Hospital Records Please note: It is extremely important that patients with Cystic Fibrosis are not recorded as Type 1 in error. Please ensure care is taken when recording if the patient has Type 1 diabetes. Does the patient have Type 1 diabetes? Yes No If no, which form of diabetes does the patient have? Type 2 Cystic Fibrosis Pancreatic MODY Secondary Other 1. Date of data collection: D D M M 2. Year of birth: 3. Year of diagnosis: 4. Course date: D D M M 5. Country of Birth: 6. Is English your first language? Yes No 7. Gender: Male Female 8. Ethnicity: White Black Mixed Asian (Indian, Pakistani, Bangladeshi) Chinese Other 9. Do you Smoke? Yes Ex. Smoker Never smoked 10. Where do you receive your diabetes care? GP only Specialist care 11. Post code (Excluding last 2 letters): DAFNE F04.009, Version 8 October 2013 Page 1 of 7

2 If no data is available for any of the results please select the relevant No Data Available tick box Note: Only enter one value for HbA1c. Mmol/mol if available, if not %. Please enter value direct from source data. The database will automatically calculate the remaining value. 12. Test Date Result HbA1c D D M M % Range: ) HbA1c D D M M mmol/mol (Range: ) Test Date Result Creatinine Cholesterol Triglycerides HDL cholesterol LDL cholesterol egfr D D M M D D M M D D M M D D M M D D M M D D M M umol/l (Range: ) (Range: ) (Range: ) (Range: ) (Range: ) Above 60 Above 90 mls/min (Range 10-90) 13. Date of last full annual review: D D M M 14. Date of last retinal screening (including retinal photography): D D M M 15. Weight kg (Range: ) 16. Height cm (Range: ) 17. Blood pressure: / (Range /0-200) 18. Pre-DAFNE insulin regimen average daily dose: Quick Acting (QA (Range: 0-199) Background Insulin (BI) (Range: 0-199) Pre-mixed Insulin (Mix) (Range: 0-199) QA:CP Ratios :1b :1m :1e :1s (Complete only if ratios are in use prior to DAFNE) DAFNE F04.009, Version 8 October 2013 Page 2 of 7

3 19. Pre-DAFNE Number of injections per day: Quick Acting (QA) (Range: 0-10) Background Insulin (BI) (Range: 0-4) Pre-mixed Insulin (Mix) (Range: 0-4) 20. Pre-DAFNE Insulin type: QA: Human (Humulin S; Actrapid; Insuman Rapid) Animal (Hypurin Neutral) NovoRapid Humalog Apidra BI: Human (Humulin I; Insulatard; Insuman Basal) Animal (Hypurin Isophane) Lantus Levemir Tresiba Mix: Human (e.g. Humulin M3; Mixtard 30) Animal (Hypurin Mix) Analogue (e.g. Humalog Mix 25; Novomix 30) 21. Are you being considered for insulin pump therapy? Yes No Yes No Already using pump Year commenced pump 22. Appearance of injection sites is Lipohypertropy present? Yes No 23. Medication: Lipid lowering (Statin; Fibrate; Ezetimibe): Yes No Antiplatelet agent (Asprin; Clopidrogel; Dipyridamole) Yes No Medication for depression (exclude antidepressants for neuropathy) Yes No 24. Have you been pregnant since you have had diabetes? Yes No Are you pregnant now? Yes No Current gestation (weeks) (Range: 6-45) DAFNE F04.009, Version 8 October 2013 Page 3 of 7

4 25. Complications prior to DAFNE: Yes No If yes, please record below which complications are present and the date of onset for each where applicable. Hypertension Complication Present ( ) Year of onset MI Coronary revascularisation Peripheral revascularisation CVA Painful neuropathy Foot ulcer Amputation toe Amputation above toe level Retinopathy Proliferative Laser Rx Registered partially sighted Registered blind Microalbuminuria (Female = greater than 3.5 on 2 occasions, at least 1 early morning urine) (Male = greater than 2.5 on 2 occasions, at least 1 early morning urine) Proteinuria (Dipstick positive and/or ACR greater than 30 on 2 occasions and/or greater than 300mg/l in 24 hours) Dialysis Renal Transplantation Erectile Dysfunction 26. Total number of diabetes related inpatient episodes in the last year (Range: 0-20) DAFNE F04.009, Version 8 October 2013 Page 4 of 7

5 27. Please record the primary reason and length of stay for each diabetes related inpatient episode in the last year in the table below Admission 1 Primary Reason For Admission No of days in Hospital (Select one reason only) DKA Range: (0-100) Hypoglycaemia Range: (0-100) Myocardial Infarction Range: (0-100) Ischaemic Heart Disease Range: (0-100) Unstable Angina Range: (0-100) Heart Failure Range: (0-100) Foot Ulcer Range: (0-100) Renal Disease Range: (0-100) Admission 2 Primary Reason For Admission No of days in Hospital (Select one reason only) DKA Range: (0-100) Hypoglycaemia Range: (0-100) Myocardial Infarction Range: (0-100) Ischaemic Heart Disease Range: (0-100) Unstable Angina Range: (0-100) Heart Failure Range: (0-100) Foot Ulcer Range: (0-100) Renal Disease Range: (0-100) Admission 3 Primary Reason For Admission No of days in Hospital (Select one reason only) DKA Range: (0-100) Hypoglycaemia Range: (0-100) Myocardial Infarction Range: (0-100) Ischaemic Heart Disease Range: (0-100) Unstable Angina Range: (0-100) Heart Failure Range: (0-100) Foot Ulcer Range: (0-100) Renal Disease Range: (0-100) All Remaining Admissions No of days in Hospital Do not record reasons only number of days Range: (0-366) 28. How many admissions due to Diabetic Ketoacidosis (DKA) have you had in total? Total Number Ever (Range: 0-99) Number in the last year (Range: 0-99) DAFNE F04.009, Version 8 October 2013 Page 5 of 7

6 29. Number of telephone contacts regarding your diabetes with any healthcare professional in the last year (Range: 0-120) 30. Number of face to face/clinic contacts regarding your diabetes with any healthcare professional in the last year (Range 0-19) 31. Please note total number of blood tests a) On average, over the last 2 weeks, how many blood tests have you done each day? Please mark one answer only or more b) On average, over the last 2 weeks, how often did you record those blood tests in your DAFNE diary? Please mark one answer only. Never Rarely (about 25% of the time) Sometimes (about 50% of the time) Often (about 75% of the time) All of the time 32. In the last year have you had a hypoglycaemic episode you were unable to treat yourself, ie had someone to help you? Yes No Please complete all questions below Please go to question Total number of hypoglycaemic episodes you were unable to treat yourself in the last year 34. Total number of hypoglycaemic episodes requiring paramedic assistance in the last year 35. Total number of hypoglycaemic episodes requiring A&E attendance or hospital admission in the last year 36. Total number of hypoglycaemic episodes when you have lost consciousness in the last year (Range: 0-99) (Range: 0-99) (Range: 0-99) (Range: 0-99) 37. Do your symptoms of hypoglycaemia usually occur at a blood glucose level of: Greater than/equal to 3itre Less than 3itre Do not feel symptoms Data collected by (Print name) Signature DAFNE F04.009, Version 8 October 2013 Page 6 of 7

7 Background Insulin Adjustment pre-course Recommendations for insulin regimen for the start of the DAFNE course: (tick all that apply and give details where required) No changes recommended Switch QA type to: (details) Reduce doses of QA to: units / :1 ratios Switch BI type to: (details) Reduce dose(s) of BI to: units am / units pm Change from once daily to twice daily BI: Change from Mix to MDI: (Details) Data collected by (Print name) Signature DAFNE F04.009, Version 8 October 2013 Page 7 of 7