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Diabetes Registration Form

Physician:

Don't Know
Social Security Number: (optional)
Name (Last):*
Name (First):*
Name (M.I.):
Address: *   Apt #:  
City:*
State:*
Zip Code:*
Date of Birth:*
Sex:*
Male      Female
Race:*
Marital Status:*
Employment Status:*
Religious Preference:
Do you have a living will?
Yes   No
Durable Power of Attorney?
Yes   No
Contact Information Relationship to Patient Ok to leave info regarding your care
Primary Phone: Yes    No
Secondary Phone: Yes    No
Alternate Phone/Pager: Yes    No
Email Address: Yes    No
Fax Number: Yes    No
Emergency Contact Name:
Emergency Contact Phone:
Yes    No
I hereby authorize for Diabetes Center personnel to contact me and/or my emergency contact and to leave necessary information related to my diabetes care via voice mail, cell phone, text, or e-mail as indicated by my selections above.

Primary Insurance

None
*Are you the primary policy holder?    Yes   No Policy Number:  
Primary Policy Holder's Name*
Policy Holder's Date of Birth*
Policy Holder's SSN (optional)
Primary Policy Holder's Address: Apt #:  
City:
State:
Zip Code:
Relationship to Patient*
Insurance Company*
Employment Status*
Employer (or retired / not employed)*   

Secondary Insurance    Not Applicable    Applicable

Are you the primary policy holder? Yes   No Policy Number:  
Secondary Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's SSN (optional)
Secondary Policy Holder's Address: Apt #:  
City:
State:
Zip Code:
Relationship to Patient
Insurance Company
Employment Status
Employer (or retired / not employed)   

Medicare

Do you have Medicare?    Yes    No

  1. Has the Department of Veteran Affairs (VA) authorized and agreed to pay for care at this facility?    Yes    No
  2. Please check Primary Reason you are CURRENTLY on MEDICARE.
    Due to age (Date of Retirement: )
    Due to End Stage Renal Disease (ESRD)
    1. Have you received a kidney transplant?   Yes (Date of transplant: )    No
    2. Have you received maintenance dialysis treatments?   Yes (Date dialysis began: )    No
    3. Are you within the 30 month coordination period?   Yes No
    4. Are you entitled to Medicare on the basis of ESRD and age?   Yes No
    5. Are you entitled to Medicare on the basis of ESRD and disability?   Yes No
    6. Was your initial entitlement to Medicare (including simultaneous entitlement) based on ESRD?   Yes No
    7. Does the working aged or disability MSP provision apply (i.e., is the GHP primary based on age or disability entitlement)?   Yes No
    Due to Disability (Date of Disability: )
  3. Do you have group health plan coverage (GHP)?    Yes    No
    1. If yes, is your GHP coverage based on your own, or a family member's, current employment?   Yes No
    2. Does the employer that sponsors your GHP employ 20 or more employees?   Yes No
    3. Does the employer that sponsors your GHP employ 100 or more employees?   Yes No
  4. Date of spouse's retirement    N/A

Nutrition Assessment

Do you have difficulty swallowing or chewing? Yes    No
Do you have chronic constipation? Yes    No
Do you have diverticulosis? Yes    No
Do you have diverticulitis? Yes    No

If "Yes" to any question above, list foods that you avoid:

Have you lost or gained any weight in the past 6 months? Yes    No
If "Yes", was the weight loss intentional? Yes    No    Not Applicable   
On a normal day, what time is your first meal?
What is the earliest or latest time you would eat your first meal? Earliest:    Latest:
What do you normally eat for you first meal?
How much?
What do you normally drink for you first meal?
How much?
On a normal day, what time is your second meal?
What do you normally eat for you second meal?
How much?
What do you normally drink for you second meal?
How much?
On a normal day, what time is your third meal?
What do you normally eat for you third meal?
How much?
What do you normally drink for you third meal?
How much?
Do you snack? Yes    No
If "Yes", how many times a day do you snack?
List foods that you use for snacks:
Do you eat at least 2 servings of fresh or frozen fruit per day? Yes    No
Do you eat at least 2 servings of fresh or frozen vegetables per day? Yes    No
How much water do you drink per day?
Do you fast? Yes    No
If "Yes", how long?
Do you avoid or limit any foods for religious purposes? Yes    No
If "Yes", please explain:
Do you drink milk? Yes    No
If "Yes", what type of milk do you drink?    1%    2%    Whole    Skim    Almond    Soy
Do you drink alcohol? Yes    No
If "Yes", what type of alcoholic beverage do you drink?    Beer    Wine    Mixed Drinks
If "Yes", how often do you drink?    1-2 drinks/day    2+ drinks/day    Weekends    Special Occasions    Other
Please check all foods that you eat    Pork    Chicken    Turkey    Fish    Beef
Please list anything else to know about what, or how, you eat:

Health History Assessment

HEALTHCARE PROVIDERS
Primary Care Physician: Phone: Fax:
OB: Phone: Fax:
Endocrinologist: Phone: Fax:
Pharmacy: Phone: Fax:

DIABETES SPECIFIC
Does anyone in your family have diabetes?    Parents    Siblings    Multiple    None    Unknown
Have you been to the Emergency Room (ER) or admitted to the hospital in last 6 months for diabetes:    Yes    No

DIABETES COMPLICATIONS/COMORBIDITIES
CHECK ALL AREAS IN WHICH YOU HAVE ANY PROBLEMS OR HAVE RECEIVED MEDICAL TREATMENT AND BRIEFLY EXPLAIN
Cardiovascular (Heart/Circulation) Mental Health
    High Blood Pressure     Depression
    High Cholesterol     Anxiety
Heart Disease / Heart Attack Kidney Disease
Eye Disease Nervous System / Nerve Disease
Feet and Lower Limbs     Seizure Disorder
Gastrointestinal (Digestion) Lungs
Liver Disease     Asthma
Metabolism / Thyroid Disease     COPD
Stroke Pancreatitis

MEDICATIONS
LIST YOUR PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS, INCLUDING ASPIRIN, VITAMINS, INHALERS, AND HERBAL SUPPLEMENTS
Medication Name: How Much Do You Take? When Do You Take the Medications?
ARE YOU ALLERGIC TO ANY MEDICATIONS? IF YES, LIST BELOW.
1.
2.
3.
4.

MEDICATION ADHERENCE
In an average week, how many times do you miss your diabetes medication(s):
Never    1x per week    2-3x per week    4-6x per week    7 or more x per week   
What are the reasons that you miss your diabetes medication(s) (Check all that apply):
I forget    The cost    I have to take the medication too often    My prescription is too hard to follow
The side effects    I don't need the medication    I don't think the medication works    Depression    Other   

BLOOD GLUCOSE MONITORING
How often do you check your blood glucose (blood sugar?)
What time of day do you monitor? Fasting    Before Breakfast    After Breakfast    Before Lunch    After Lunch
Before Dinner    After Dinner    Bedtime    12 AM    3 AM    Random    Other

HYPERGLYCEMIA
Have you ever experienced hyperglycemia (blood sugar above 250 mg/dL)? (symptoms such as thirst, dry mouth, tiredness, frequent urination, or a blood sugar reading of over 250 on you blood glucose meter)    Yes    No

HYPOGLYCEMIA
Have you every had hypoglycemia (blood sugar below 70 mg/dL)? (symptoms such as sweating, anxiety, trembling, or headaches)    Yes    No
How often do you have hypoglycemia?    1-3x per week    4-6x per week    7 or more times per week    Rarely
Unknown
How do you treat hypoglycemia?    Juice    Soda    Milk    Sugar    Candy    Glucagon    Glucose Tabs
Food    Do Nothing    Other
Are you able to feel when your blood glucose is low?    Yes    No

PHYSICAL ACTIVITY
How often are you physically active?    less than 1 time per week    1-2x per week    3-5x per week    6-7x per week
7+ per week
Do you have any physical limitations that prevent you from being physically active or exercising?    Yes    No
If "Yes", please specify:   

SELF-ASSESSMENT
How would you rate your stress level?    High    Medium    Low
Do you carry identification that states that you have diabetes?    Yes    No
Do you know your most recent A1C?    Yes (please specify)    No
How often do you examine your feet?    Daily    Every other day    Occasionally    Rarely
Do you have any foot problems?    Amputations    Callus(es)    Bunions    Neuropathy    Ulcer    None
Fungal Toenail(s)    Structural Deformity    Other
Do you currently use tobacco?    Yes    No      How much?
Have you ever been referred into a program to stop tobacco use?    Yes    No

FEMALE SPECIFIC
Are you sexually active?    Yes    No Do you use birth control?    Yes    No
Are you considering getting pregnant?    Yes    No Are you currently pregnant?    Yes    No

IF CURRENTLY PREGNANT
Have you ever been Pregnant?    Yes    No If "Yes", how many times? How many babies are you carrying?
How many live births? How may weighed more than 9 pounds?
Have you ever had Gestational Diabetes?    Yes    No
Have you had any other complications with past pregnancies?    Yes    No
Please specify
How much did you weigh before you got pregnant? When is your due date?

LEARNING PREFERENCES AND BARRIERS
Primary Language    English    Spanish    Vietnamese    Chinese    French    Other:
How do you learn best    Computer    Reading    Lecture/Audio    Hands On Demonstration    Video
Group Discussion
Do any of the following make learning difficult?    None    Vision    Hearing    Learning Disability    Language
Reading/Low Literacy    Low Health Literacy    Memory Loss    Denial of Diabetes    Work Schedule
Lack of Family Support    Competing Activities    Food Issues    Unresolved Eating Disorder    Grief
Financial Concerns    Transportation    Other   

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