Dr. Russell new patient DIABETES questionnaire
Name: ______________________________________ Date of Birth: __________________________
Primary Care physician: ________________________
How long have you had diabetes for and how were you diagnosed?
____________________________________________________________________________________
Diabetes Education: (formal teaching/when, level of knowledge, interest in education classes)
______________________________________________________________________________
What medications (pills and/or insulin) have you tried in the PAST for your diabetes?
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What medications (pills and/or insulin) are you currently using for your diabetes?
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How often do you check your sugar? ______________________________________________
What is the typical range of your blood sugar at the following times of day?
Before breakfast_____________
2 hrs after breakfast ______________
Before lunch ________________
2 hrs after lunch _________________
Before dinner _______________
2 hrs after dinner ________________
At bedtime _________________
In the middle of the night ___________
What do you typically eat for the following meals: (please mention if you count carbohydrates?)
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Breakfast: ________________________________________________________________
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Lunch: ___________________________________________________________________
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Dinner: __________________________________________________________________
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Snack(s): _________________________________________________________________
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Do you exercise? If so, how often and what type? _______________________________________
Any hypoglycemia? (blood sugar less than 70 during the day or less than 100 at night)? If so, what
time of day and how often? _____________________________________________________________
What are the usual causes of your hypoglycemia (circle all that apply)
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missed/small/delayed
meals or snacks
alcohol
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increased activity
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too much insulin
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unexplained
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other--
What symptoms do you have when your sugar is low?
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Please circle what symptoms you have when your sugar is high:
Fatigue
excessive thirst
excessive urination
headache
urinating at night
Complications of diabetes:
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Any history of heart disease, heart attack, heart stents, heart surgery
Uses aspirin daily
History of mini stroke (TIA) or stroke (CVA)? If so, when? ____________________
Residual side effects ____________________________
Numbness/tingling/burning/lack of feeling in your feet or hands
kidney disease--
Last urine microalbumin: __________________________
Last DILATED eye exam____________________________
Did they see any problems with the retina (blood vessel at back of eye), or glaucoma?
 Yes __________________________________________________________________________
 No
Any problems with feeling dizzy or having blood pressure drop when standing up?
 Yes __________________________________________________________________________
 No
Any problems with gastroparesis (stomach not emptying properly)?
 Yes __________________________________________________________________________
 No
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Illness/Medical History
Diabetes
Heart Disease
Thyroid Disease
Adrenal Disorder
Pituitary Disease
Osteoporosis
Calcium problem
Kidney disease
Stroke
Cancer (and what type)
High blood pressure
High cholesterol
Other
Yourself
Family Members
Details
Please list any former surgeries and dates if known:
Surgeries:
Date:
Please list all medications, INCLUDING over the counter and herbal medications, with doses if known:
Medication
Dose
Frequency
Are you allergic to any medications? If so, what reaction did you have? _________________________
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Social History:
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Current smoker, if checked, how much and for how many years? _________________________
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Smoked in the past, If checked, how much and for how many years? ______________________
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Drink alcohol, If checked, how much and how often? ___________________________________
Marital Status: _________________________
Are you sexually active?
 Yes
 No
For women only: Are you currently or in the near future interested in becoming pregnant?
 Yes
 No
Review of systems:
Please circle any CURRENT symptoms you are having on a FREQUENT basis
General
Head
Neck
Heart
Lungs
Gastrointestinal
Urinary
Reproductive
Skin
Blood
Endocrine
Musculoskeletal
Neurological
Psychological
Fatigue, generalized weakness, weight loss, weight gain, abnormally thirsty
Visual difficulty, double vision, blurred vision, change of voice, difficulty
swallowing, painful swallowing
Neck pain, neck swelling
Fast heart rate, palpitations, chest pain, shortness of breath with exertion
Shortness of breath, cough, difficulty breathing when lying down, difficulty with
breathing when raising both arms above your head
Abdominal pain, nausea, vomiting, diarrhea, constipation
Frequent daytime urination, frequent nighttime urination, frequent urinary or
vaginal infections
For women: Last menstrual period _________, irregular periods, pregnant, post
menopausal (including surgical menopause)
For men: low libido, difficulty with erections, decreased shaving frequency
Dry skin, moist skin, rash, easy/excessive bruising, thin skin, excessive acne
For women only: male pattern hair growth
Prolonged bleeding, other blood disorders
Heat intolerance, cold intolerance
Poor muscle strength, previous fracture, osteoporosis, previous foot ulcer, calf
cramping
Burning/numbness/tingling of feet, tremors, jitteriness
Depression, anxiety
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-------------------------------------------------------FOR STAFF USE ONLY-------------------------------------------------------
Physical Examination:
Pulse
Resting Rate
Blood Pressure
Height
Weight
BMI
Eyes: pupils equal round and reactive to light, injection, proptosis, lid lag, stare, icterus
HEENT: moist mucus membranes, no oral lesions,
Lymphadenopathy: Palpable abnormal lymph nodes: ant/post cervical, supra/infra clavicular
Neck: Thyromegaly _________, trachea deviated
Heart: irregular rate _______, irregular rhythm,
Chest: lungs clear to auscultation, negative Pemberton’s sign
Abdomen: soft, nontender, good bowel sounds,
Musculoskeletal: grossly intact muscle strength, no tenderness to palpation along spine/hips, intact
distance between pelvic brim and lower ribs
Extremities: no edema, palpable peripheral pulses, onychomycosis toenails
Neurological: 2 + DTRs, intact monofilament/vibratory sensation, alert, oriented
Skin: no ulcers on feet, dry skin, rash, jaundice
Psych: normal mood/affect, normal judgment
Other: ____________________________________________________________________________
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Assesment/Plan:
DM Type 1 / 2 controlled/uncontrolled with complications:
Goals for A1C per AACE is <6.5% or per ADA <7%. The patient is currently at/not at goal.
Patient is/is not up-to-date on last eye exam (
Patient is/is not up-to-date on foot exam (
sensation
): yes/no retinopathy
): intact/impaired monofilament/vibratory
Patient is/is not up-to-date on urine microalbumin screening (normal/abnormal
)
Patient is/is not taking a daily ASA
Patient is/is not up-to-date on cholesterol screening (
).
Goal for LDL is <100 – at goal/not at goal in _____________________
Blood pressure is/is not at goal of <130/80.
Female pt advised to avoid pregnancy while on statins and ACEIs
Vit D deficiency can be associated with insulin resistance and increased risk of autoimmune conditions.
Level ____ in _________
Last TSH (for DM1 pts)_______________
Return to Clinic ___________________ Physician Signature: ___________________________________
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