Tampa
General
Hospital
Diabetes Self-Management Education
Assessment and Registration Form
Last
Date: -------
First
___________
Birthdate:
Age__
City
Sex__
What type of diabetes do you have?
St__
Race
Zip
Phone
_
Martial status__
Pre-Diabetes;Type 1
Type 2 --. GDM
I
Don't know
Do you have a family history of diabetes?. No Yes
How long have you been diagnosed?
Have you ever been a patient at TGH? -:Admitted ~ER
What is your doctor's first & last name?
Both
Never
What is the phone #?
_
What is your doctor's address?
----------------------------
Are you employed? _ Yes, Type of
________
oBy TGH No . Retired . Disabled
Do you have health insurance? - No Yes What type? ~:Medicare .Medicaid
Hillsborough County (HCHCP)
Managed Care/Private
How many years of school did you complete?
_
No formal Elementary HS grad -College grad
Is there anything that would interfere with your learning in class? . No - Yes, such as:
Hearing
Vision .Lanquaqe Heading ability .Pain .Other
_
NUTRITION
What is your height?
Your weight?
Do you consider yourself overweight? No .Yes
What kind of meal plan do you follow?
_
Who does the cooking?
Have you seen a Dietitian?
How many meals a day do you eat?
How many snacks?
How many fruits per day do you eat? __
How often do you eat out per week?
Vegetables__
If so, when?
_
Evening snack" : No .Yes
High fat/fried foods
Salty foods
_
Do you drink liquids with sugar in them?
Do you have cultural or religious dietary influences?
_
_
EXERCISE
Do you exercise? No Yes What type?
How often?
Do you carry a source of sugar & 10 when you exercise?
How long?__
Do you exercise with a partner?
_
PSYCHOSOCIAL
How do you handle stress?
Who is your support person?
Any issues regarding diabetes (cost of supplies, feelings, concerns)?
What are you most interested in learning from the class?
What ongoing support do you have (support group, magazines, websites, gym)
(Continue on backside of form)
_
_
_
_
MEDICATIONS
Name of
do you take for diabetes?
_______
Times a day
_
Name of
_______
Times a day
_
Name of
_______
Times a day
_
Insu
What kind of medications
----------------------
oPen oVial
Dose
c=Pen cvia]
Who gives the injections?__
Times a day
------________
Times a day
Where do you give them?
How long ago?
COMPLICATIONS
Have you ever been in a coma (diabetic/insulin)? __
Has your blood sugar ever been over 400?
_
Do you use a sharps box? __
MONITORING
Do you check your blood sugar?
Name of monitor?
What is your usual blood sugar before eating?
After eating?
What was your last A 1 C (eAG)?
-------------
How many times/day?
Target range?
_
_
Do you ever check ketones?
How many times?__
When?
_
_
Has your blood sugar ever been under 40 ? __
Do you have any chronic complications? (check all boxes that apply)
Feet: .. sore ' callus ',. fungus .arnputation
Dental: :~ decay gingivitis
Sexual: .Jmpotence.vaqinal dryness .yeast
Mental Health: ,-depression anxiety
liver: hepatitis, , cirrhosis, - high LFT
_
Eyes: retinopathy ~ cataracts •. glaucoma poor vision
Heart: Lheart attack stroke "cholesterol' blood pressure
Kidney problernsrurme protein/microalbumin ~dialysis
Nerves: : pain/loss of feeling in hands or feet
Stomach: ~gastroparesis :-~gas/bloating'~.diarrhea
Do you have other medical problems? ..' No .Yes, List
Are you taking other medications other than your diabetes meds? : No 'Yes,
Do you use tobacco? _
Type
Years? _
MISCfFOLLOW-UPfCARE
When was your last doctor visit?
Amt/day
foot exam?
Drink alcohol? _
eye exam?
# drinks/day_
dental exam?
Have you ever had diabetes education before? ----When? ---Where? _------Who told you about this class?
Would you be interested in a support group _ No ' Yes
How would you rate your present health?
EDUCATION PLAN
_ Disease process
Nutrition
r
Physical Activity
: Excellent
_Good
._Fair
Comprehensive Class ~ Basic Class _ Individual
: Medications
'Poor
Very Poor
Emphasizing:
Behavior Change Strategies
- Monitoring
_- Risk Reduction
': Prevent Complic. (Acute, Chronic)
PLEASE BRING COMPLETED FORM TO CLASS
6/13/16X:IOSMEIOSME Assess Form .doc
2
.. Psychosocial Adjustment
WELCOME
TAMPA GENERAL HOSPITAL
Please provide us with the following information necessary to register you for the Diabetes
Education Class.
Please bring this completed form with you, when you come to the class.
Patient Name:
SS#
-------------
Address:
State
Zip
Date of B.irth: ---Next of Kin/Emergency Contact:
_
Insurance:
Primary insurance:------------_.
Subscriber information: ~
Subscriber Name:
Subscriber date of birth ---
--------------~------------------------------------
Relationship to Patient:
-----------------------------------------------Employer:
---------------------------------------------------------