Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS Please complete the following form by filling in the blanks or by circling the answer provided. Last Name: First Name M.I. Address: City, State, Zip: County: Date of Birth: / / SS# - - Home Phone: ( ) Cell: ( ) Work: ( ) Email: Referring Physician: Phone ( ) Primary Physician: Phone ( ) Employer: Phone( ) Marital Status: Single Married Divorced Widowed Separated Race: White Black Native American/Eskimo Hispanic Asian Pacific Islander Other Primary Ancestry: European African Hispanic American Indian Arab Finnish Other Language: English Spanish French Other Male or Female Your Type of Diabetes: Type 1 Type 2 (Insulin-Treated) Type 2 (Non-Insulin Treated) Gestational Diabetes Pre-Diabetes Other Diagnosis Spouse or Nearest Relative Phone( ) Relationship to you Second Contact Phone( ) Relationship to you Any Allergies? No Yes If Yes: Medicine Allergies Food or other Primary (first) Insurance Contract or ID # Group # Name of Policy Holder Policy Holder s Date of Birth / / Policy Holder s S.S. # - - Company or Employer Insurance is Through Secondary Insurance Contract or ID # Group # Name of Policy Holder Policy Holder s Date of Birth / / Policy Holder s S.S. # - - Company or Employer Insurance is Through Date Staff Signature 1
Borgess Diabetes Center (269-226-8321) Please answer the questions by filling in the blanks or by circling the answer provided. Do you have any cultural or religious practices that may influence how you might care for your diabetes? Yes No If yes, please explain: Do you have anything that may affect your learning? Personal Information Hard of Hearing Poor vision Trouble Reading Memory Problems Don t Speak English Physical Limitations Pain Financial Concerns Favorite ways to learn? Read Video Individual Lecture Small Interactive Groups Other Have you had previous diabetes education? Yes No If yes, when Diabetes History What is the name and phone number of your pharmacy? What glucose meter do you use? (Bring it with you to your appointment) Where do you get your glucose meter supplies? If you wear an insulin pump what type do you wear? How many times do you check your blood sugar each day? 0 1 2 3 4 5 6 7 8 9 How many times do you experience a blood sugar less than 70mg/dL each week? How many times do you experience a blood sugar over 200 mg/dl each week? Do you test for ketones? Yes No N/A Do you change your food based on your blood sugar? Yes No If Yes Explain: My last Hemoglobin A1C was How many times do you exercise in a week? Tobacco Use: None Quit Currently use, don t want to quit Currently use, want to quit I smoke packs per day Do you use any street drugs? Yes No Methods I have tried in the past to quit If yes, how often? Patient Name: DOB Rev 4/2012 2
Borgess Diabetes Center (269-226-8321) Please rate your level of success for each of the following areas: (circle your answer) Adapting to change none little moderate very Managing Stress none little moderate very Medications: Please list all of the medications you take, including over the counter medications and supplements. Name of DIABETES Medication Dose/Amount Frequency Before meals, with meals or after meals If you take insulin or other injectable diabetes medications, do you give your own shots? Yes No If no, who helps you? I give my injections in my (circle all that apply) thigh arm abdomen buttocks other Please select method of insulin delivery: pen vial (bottle) and syringe Where do you store your insulin/injectable diabetes medication? Refrigerator Room temperature List all other medicines you take, including over the counter medicines, herbs, supplements and the reasons you take them. Name of other medications Dose/Amount Frequency When taken Taken for Patient Name: DOB Rev 4/2012 3
Borgess Diabetes Center (269)226-8321 I wear diabetes identification: Yes No Have you experienced a loss or change in hearing? Yes No Are you being treated for high blood pressure? Yes No Last Dr s visit for blood pressure Have you been hospitalized or seen in the ER in the last two years for diabetes? Yes No Have you had a flu shot? Yes No If yes, when Have you had a pneumonia shot? Yes No If yes, when When was your last visit to have your eyes examined? Do you have any eye problems? Yes No If yes, what problems When was the last time your doctor examined your feet? How often do you check your feet? Daily Weekly Don t check my feet Do you have numbness or tingling in your feet? Yes No Other problems with your feet? Do you have numbness or tingling in your hands? Yes No Height Weight Goal Weight Recent change in weight? No Gained Lost How much gained or lost? pounds in the past months. Was this unexpected? Yes No Do you have a history of an eating disorder? Yes No If Yes, explain Do you drink alcoholic beverages? Yes No Diet and Nutrition List meal and snack times and what you would typically eat at these times including beverages that you might have. (This is important, as our dietitian will develop your personal meal plan with this information.) Breakfast time Lunch time Supper time Morning snack time Afternoon snack time Evening snack time Patient Name: DOB Rev. 4/2012 4
Borgess Diabetes Center (269)226-8321 TELL ME MORE ABOUT THE FOLLOWING TOPICS (Please check as many as you wish) General facts about diabetes Feelings related to having diabetes Nutrition Insulin/Injectable diabetes medications Oral diabetes medications High blood glucose Low blood glucose Glucose Monitoring Hemoglobin A1C Ketone Testing Pattern Management (Determining why my blood glucose levels go up and down) Exercise Long term complications of diabetes Hygiene Illness/Use of non-prescription medications and diabetes Use of alcohol Smoking cessation Impotence and sexuality Pregnancy and pre-pregnancy planning Benefits/responsibilities of self-care Options for improved blood glucose control Use of health care system Community resources Other comments: Do you have any other comments or things we should know about you so that we can plan your education program to be most helpful to you? Women of Childbearing Age: Plan to become pregnant? Yes No Not applicable Prior gestational diabetes? Yes No If pregnant, due date Number of previous preganancies Birth weights Pre-pregnancy weight Obstetrician Please complete the questions on the back of this page Patient Name: DOB: Rev 4/2012 5
Borgess Diabetes Center (269)226-8321 Please take a few moments to respond to the following diabetes statements (yes if you agree with the statement, no if you disagree with the statement). If you do not know the response to a statement you may take a guess. Your responses help us develop a personalized diabetes education plan for you. Yes No Having diabetes means my body does not make enough insulin, or the insulin my body makes does not work very well. Yes No Fat is the nutrient in food that most affects blood sugar. Yes No Carbohydrate sources include starches, fruits, milks and sweets. Yes No Exercise can cause low blood sugar even several hours after you are done. Yes No If you are ill and your blood sugar is elevated, you should match your usual carbohydrate intake with liquids or soft foods Yes No A blood sugar of 150mg/dL before a meal is within target range Yes No Delaying meals or snacks can cause insulin reactions (low blood sugar). Yes No Causes of high blood sugar may include too much food, stress, or illness. Yes No Symptoms of LOW blood sugar are thirst, blurred vision, and excessive urination. Yes No Nerve fiber damage in diabetes can cause severe pain or total loss of feeling. Yes No High cholesterol and/or triglycerides can occur when diabetes is out of control. Yes No A lifestyle change can be increased exercise, diet changes, losing weight, stopping smoking, or just learning to relax. Yes No Smoking, high cholesterol, high blood pressure, obesity and stress increase the chance for complications of diabetes. Yes No Denial, anger, bargaining, depression, and acceptance are normal feelings that occur to people who must live with diabetes. Yes No The glucose meter test strips have expiration dates. Yes No Only people taking insulin need to wear a medical ID. Yes No At the beginning of every bottle/box of strips you should check the strips with the control solution. Yes No An A1C of 8.0% is considered good control. Thank You Patient Name DOB Rev. 4/2012 6