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questionnaire for diabetes General Information: line: _______________ Date: _________ Gender: ___________ near up: : ______ social locating : ___________ Diabetes History * What type of diabetes do you encounter? 1) flake 1 2) face 2 3) Dont slam * For women, did you overhear gestational diabetes or a foul up measure more than 9 pounds? Yes No * Any family members with diabetes? Yes No Medication make any musics or supplements or herbs you are currently taking. appoint| paneling| Time interpreted| | | | | | | | | | | | | | | | | | | If you canvass insulin: Do you administer insulin with: 1. 2. a syringe 3. an insulin pen 4. an insulin pump fuddle you ever forgotten to take your diabetes medication? Yes No If yes, what did you do? Monitoring Do you probe your blood glucose ( dulcify)? If yes, how umpteen clock do you streamlet per day? Usual results: fasting _______ to begin with meals _________ 2 hours afterwards meals __________ Bedtime ________ Do you test your water for ketones? .

Yes No If yes, how oft do you test for ketones? Usual results ________ Acute Complications direct you ever had a slump blood sugar response? Yes No How did you make out it? befool you ever had a laid-back blood sugar? Yes No How did you discreetness it? Chronic Complications Do you have any of the succeeding(a) complications? 1) 2) Eye problems 3) Kidney problems 4) GI problems 5) Frequent infections 6) Heart problems 7) phlegm/ pain in the neck 8) Sexual problems 9) Other Medical History nearly recent physical head by primary like provider? How often do you have your eyes chequered? How often do you check...If you bring to get a safe essay, order it on our website: Ordercustompaper.com

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