Diabetes Evaluation

Please fill this evaluation out to the best of your ability. The provider will be going over this in detail
with you during your office visit.

Patient Name:

DOB:

1. Have you ever been diagnosed with diabetes?YesNo
If yes, when?(year)

2. Have you ever been on medication for diabetes?YesNo

If yes, Please check one

Oral MedicationInsulin

3. Are you currently on medications for diabetes?YesNo

4. Do you follow a diabetic diet? YesNo
5. Do you know how to count carbohydrates? YesNo
6. Is exercise a part of your daily life? YesNoIf yes, how many times a week? . How many minutes?mins.

7. When was your last eye exam where they dilated your eyes? (put drops in that made your vision blurry?):(month/year)

8. Do you experience any numbness/tingling/burning in your hands or feet? YesNoExplain:

9. Do you experience any symptoms of low or high blood sugar? YesNo

10. Please check if you experience any of these symptoms, regardless of answer to previous?

Extreme ThirstFrequent UrinationHungerBlurred VisionDrowsySlow Healing woundsShakyRapid HeartbeatSweatingDizzyWeaknessFatigueHeadacheIrritability

11. If you experience any of these symptoms, do they happen at a specific time of day? Please explain:

12. Do you currently check your blood sugar? YesNo
**IF YOU HAVE A METER/PUMP OR HANDWRITTEN LOGS PLEASE HAND IT TO FRONT DESK NOW**
If yes, please answer the following questions:
a) How many times a day do you check your blood sugar?
b) Do you check before or after meals? YesNo
c) Do you frequently have blood sugar levels that are greater than 120? YesNo
d) Do you frequently have blood sugar levels that are less than 80? YesNo