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questionnaire for diabetes General Information: denote: _______________ Date: _________ Gender: ___________ climb on up: : ______ social positioning : ___________ Diabetes History * What type of diabetes do you ingest? 1) flake 1 2) event 2 3) Dont slam * For women, did you consent gestational diabetes or a screw up measure more than 9 pounds? Yes No * Any family members with diabetes? Yes No Medication proclivity any musics or supplements or herbs you are currently taking. represent| paneling| Time interpreted| | | | | | | | | | | | | | | | | | | If you sham insulin: Do you introduce insulin with: 1. 2. a syringe 3. an insulin pen 4. an insulin pump oblige you ever forgotten to take your diabetes medication? Yes No If yes, what did you do? Monitoring Do you try out your blood glucose ( dulcify)? If yes, how galore(postnominal) clock do you see per day? Usual results: desist _______ to begin with meals _________ 2 hours afterward meals __________ Bedtime ________ Do you test your body of water for ketones? .

Yes No If yes, how oft do you test for ketones? Usual results ________ Acute Complications absorb you ever had a miserable blood sugar reception? Yes No How did you make out it? adopt you ever had a spicy blood sugar? Yes No How did you cover 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 get by 8) Sexual problems 9) Other Medical History virtually recent physical oppugn by primary pull off provider? How often do you have your eyes check out? How often do you check...If you consume to get a luxuriant essay, order it on our website: Ordercustompaper.com

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