Diabetes Assessment Form

North Atlanta Endocrinology & Diabetes, P.C.
Diabetes Self-Management Education

Assessment Form
Name: _____________________________________________________ Date: _______________________
Date of Birth: _________/_________/_________ Gender: F_____ M _____
Marital Status: Single _____ Married _____ Divorced _____ Widowed _____
Ethnic Background: White/Caucasian _____ Black/ African American _____ Hispanic _____
Native American _____ Middle Eastern _____ Other: __________________
What is your language preference? English _____ Other: __________________
What is the last grade of school completed? Grade school _____ High school _____ College _____
Email address: _____________________________________ (For diabetes education/follow-up ONLY)
1. What type of diabetes do you have? Type I _____ Type 2 _____ Gestational _____
Pre-Diabetes _____ Do not know _____
2. When were you diagnosed with diabetes? ________________
List of relatives with diabetes____________________________________________________________
3. Do you take diabetes medications? Yes _____ No _____ (If yes check all that apply below)
Diabetes pills _____ Insulin injections _____ Byetta injections _____ Victoza injections _____
Symlin injections _____ Combination of pills and injections _____
4. D o you have: High blood pressure _____ High cholesterol _____ Nerve damage _____
Kidney disease _____ Heart disease _____ Lung disease _____ Eye disease _____
Depression _____
5. Have you attended a diabetes education program in the past? Yes _____ No _____
How long ago? ________________
7. From whom do you get support for your diabetes? Family _____ Co-workers _____
Healthcare providers _____ Support group _____ No-one _____
8. D
o you have a meal plan for diabetes? Yes _____ No _____
If yes, please describe: _________________________________________________________________
About how often do you use this meal plan? Never _____ Seldom _____ Sometimes _____
Usually _____ Always _____
Do you read and use food labels as a dietary guide? Yes _____ No _____
Do you have any dietary restrictions: Salt _____ Fat _____ Fluid _____ Other: _______________
None _____
Give a sample of your meals for a typical day:
Time: __________ Breakfast: ____________________________________________________________
Time: __________ Lunch: _______________________________________________________________
Time: __________ Dinner: ______________________________________________________________
Time: __________ Snack: _______________________________________________________________
9. D
o you do your own food shopping? Yes _____ No _____
Cook your own meals? Yes _____ No _____
How often do you eat out? ______________________________________________________________
10. Do you drink alcohol? Yes _____ No _____ Occasionally _____ How many drinks per week _____
11. Do you use tobacco? Yes _____ No _____ Quit: _____
12. Do you exercise? Yes _____ No _____ Type ________________________ How often ___ __________
13. Do you check your blood sugars? Yes _____ No _____ How often? Once a day _____
2 or more/day _____ 1 or more/week _____ Occasionally _____
What is your blood sugar range: Before meals: _____ to _____ After Meals: _____ to _____
14. In the last month, how often have you had a low blood sugar reaction? Never _____ Once _____
One or more times/week _____ What are your symptoms? __________________________________
15. Can you tell when your blood sugar is too high? Yes _____ No _____
16. In the past 12 months which of these test/procedures you have had: Dilated eye exam _____
Urine test for protein _____ Foot exam _____ Dental exam _____ Blood Pressure _____
Weight _____ Cholesterol _____ HgA1c _____ Flu Shot _____ Pneumonia Shot _____
17. In your own words, what is diabetes? _____________________________________________________

18. How do you learn best? Listening _____ Reading _____ Observing _____ Doing _____
19. Do you have any difficulty with? Hearing _____ Seeing _____ Reading _____ Speaking _____
20. Do you have any cultural or religious practices or beliefs that influence how you care for you
diabetes? Yes _____ No _____ Please describe: ____________________________________________
21. D o you feel good about your general health? Yes _____ No _____ Not sure _____
Does diabetes interfere with other aspects of your life? Yes _____ No _____
How is your level of stress? High _____ Low _____ No stress _____
22. H ow do you handle stress? ______________________________________________________________
Do you struggle with making changes in your life to care for your diabetes: Yes _____ No _____
23. What concerns you most about your diabetes? ____________________________________________
24. What is hardest for you in caring for you diabetes? _________________________________________
25. What are you most interested in learning from your diabetes education sessions? _____________
______________________________________________________________________________________
For Women Only

2. Pregnancy and Fertility:
Are you: Pre-menopausal _____ Menopausal _____ Post-Menopausal _____ N/A _____
Are you pregnant? Y _____ N _____ When are you expecting? ________________________
__________
Are you planning on becoming pregnant? Y _____ N _____
Are you aware of the impact of diabetes on pregnancy? Y _____ N _____
Are you using birth control? Y _____ N _____ N/A _____
Please do not write below this line

Clinician Assessment Summary:
Education Needs/education plan for patient:
Diabetes Disease Process Using Medications Psychosocial Adjustment
Nutritional Management Physical Activity Preventing Acute Complications
Preventing Chronic Complications Behavior Change Strategies Risk Reduction Strategies
Monitoring
Date: _______________________ Clinician Signature: __________________________________________
HT 1/2012

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North Atlanta Endocrinology & Diabetes, P.C.

Diabetes Self-Management Education

17. In your own words, what is diabetes? _____________________________________________________

For Women Only

Please do not write below this line

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