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    Diabetes Patient Health

    These are the questions you will be asked on the Diabetes Patient Health Survey. Diabetes involves many aspects of life. This information will help us to help you. We look forward to being a part of your diabetes team.

    For a print friendly PDF version of this survey, see: Patient Health Survey [PDF] (152KB)
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    General Information  |  Diabetes History  |  Medical History  |  Nutrition  |  Exercise  |  Pain Assessment  |  Monitoring  |  Pregnancy (if applicable)  |  Risk Factors  |  Health Beliefs  |  Social/Learning History

    General Information

    • Name, Date
    • Birth date, Age, Gender
    • Best phone number, Best time to call, OK to leave messages? [Yes/No]
    • What is your preferred language? Spoken/written
    • Primary Care Doctor, Diabetes Doctor
    • If you would like to be added to a confidential mailing list to receive diabetes-related updates, you will be asked for your email address.

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    Diabetes History

    • When diagnosed? Blood glucose (sugar) on diagnosis? Recent A1C/date (if known)
    • What type of diabetes do you have? [Don’t know / Type 2 / Type 1 (Do you wear a pump?) / Other]
    • For women, did you have gestational diabetes or a baby weighing more than 9 pounds? [Yes/No]
    • Any family members with diabetes? [Yes / No - If yes, who?]
    • How do you feel about having diabetes?
    • Have you ever had diabetes education? [Yes / No - If yes, when? Where?]
    • How would you rate your understanding of diabetes? [Good / Fair / Poor]
    • Does anybody help you take care of your diabetes? [Yes / No - If yes, who?]
    • What do you want to learn? [Healthy eating / Exercise guidelines / Monitoring glucose / Medication info / Dealing with stress / Problem solving / Reducing complication risk / Other]

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    Medical History

    • How would you rate your general health? [Excellent / Good / Fair / Poor]
    • What other conditions or problems do you have? [Blood pressure / cholesterol / heart / eye / thyroid / current or recent infection / kidney / sexual / gastrointestinal / nerve (neuropathy) / depression / Other / Explain any of these]
    • Major operations / recent hospitalizations
    • Last eye exam? Last foot exam? Last medical exam? Last dental checkup? Last flu shot? Last pneumonia shot?

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    • What is your current weight? Height? What is your goal weight? Has your weight changed in the past year? [Yes / No - If yes, pounds gained / lost]
    • Do you have a history of an eating disorder? [Yes / No - If yes, describe]
    • Who cooks? Who shops? How often do you eat out and where?
    • What special food plan or diet do you follow (including any cultural/religious diet restrictions, if any)?
    • What changes have you made in your diet recently, if any?
    • Do you count carbohydrates? [Yes / No / I don’t understand the question]
    • List any food allergies or intolerances
    • Diet History (What foods do you usually eat?) List types and amounts.
    • Breakfast / Lunch / Dinner / Snacks:

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    • Have you been advised to limit exercise? [Yes / No - If yes, describe]
    • Do you exercise on a regular basis? [Yes / No / - If yes, type of exercise]
    • How many times a week do you exercise? For how long?

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    Pain Assessment

    • Are you having any pain now? [Yes / No - If no, skip this section]
    • Where is the pain? Describe
    • Are you under the doctor’s care for pain? [Yes / No]
    • Current Level of Pain: (circle the number that reflects the intensity)
      0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
      None - Mild - Moderate - Severe - Very Severe - Worst Possible
      Annoying - Uncomfortable - Distressing - Horrible - Excruciating - Agonizing
    • What is your goal? [comfortable / increase function / able to sleep / reduce intensity]
    • What do you do to manage the pain?

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    • Do you test your blood glucose (sugar)?
      Yes. My type of meter is:
      No (skip to “Lows” below)
    • What do you consider an acceptable blood glucose reading?
    • How often do you test?
    • What time(s) of the day?
    • Usual blood glucose before meals / Two hours after meals
    • Lows
      • Have you ever had low blood glucose?
        When? / Never (skip to “Highs” below)
      • Can you feel when your glucose is too low? [Yes / No - If yes, list your symptoms]
      • How do you treat low blood glucose?
      • Do you wear a medical identification bracelet or necklace? [Yes / No]
      • Have you ever been unconscious from low glucose? [Yes /No - If yes, when?]
      • Do you have a Glucagon kit at home for severe lows? [Yes / No - If yes, who in your household has been taught how to use it?]
    • Highs
      • What are your current levels of high blood glucose?
      • How do you treat the highs?
      • Do you test for ketones? [Yes / No]

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    Pregnancy (if applicable)

    • Are you pregnant? [Yes / No - If yes, expected due date]
    • Are you planning to become pregnant? [Yes / No - If no, Birth control method / N/A]

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    Risk Factors

    • Do you have trouble sleeping? [Yes /No]
    • Are you told you snore? [Yes /No]
    • Are you sleepy during the day? [Yes /No]
    • Smoke or exposure to cigarettes? [Yes /No - If yes, number of cigarettes each day]
    • Do you drink alcohol? [Yes /No - If yes, how much]
    • Do you use illicit drugs? [Yes, No - Yes, explain]

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    Health Beliefs

    • I believe following my diet is the best thing I can do to control my diabetes. [Agree / Neutral /Disagree]
    • I have some control over whether or not I get complications of diabetes. [Agree / Neutral /Disagree]
    • I feel diabetes is the one of the worst things that ever happened to me. [Agree / Neutral / Disagree]
    • I will have to or have given up many things because of my diabetes. [Agree / Neutral / Disagree]
    • If I don’t take care of myself, I believe diabetes could be a great threat to my life. [Agree / Neutral / Disagree]

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    Social/Learning History

    • How do you learn best? [Reading / Demonstration / Hands on / Watching TV]
    • Do you have difficulty with: [Hearing / Speech / Vision / Mobility / Sitting for 2 hours or more / Concentrating - Explain]
    • How would you describe the amount of stress in your life? [Low / Medium / High]
    • How do you handle it?
    • Do you have any financial concerns or worries?
    • Do you work? [Yes / No - If yes, type of work? Work hours?]
    • School/grade level completed?
    • Marital Status: [Single / Married / Domestic partner/ Divorced / Separated / Widowed]
    • Number in Household? Living situation?
    • Have you signed an advanced directive or medical power of attorney?
    • (Optional) Race/Ethnicity (for data collection purposes only)
    • What else you would like us to know about you?
    • Your expectations of our diabetes program CDS

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