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. 25 30 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 94 102 cm 80 88 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
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?
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 2 53. If you are diabetic, do you own a glucometer? Yes No, If YES, what BRAND is it?
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?
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?
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