DIABETES INFORMATION SHEET
DIABETES HISTORY
Name: Type Name.
Age: Type Age. Age/Year at Diagnosis of Diabetes: Type Age/Year.
Choose one: Type 1 ☐ Type 2 ☐
Purpose of this visit? Enter text.
How were you initially treated? Choose all applicable: Diet ☐ Pills ☐ Insulin ☐
What are/was the name of the pills you are/were taking for diabetes?
☐Metformin/Glucophage Select below. Dosage: Type Dosage.
☐Glyburide/Glipizide/Glimepiride Select below. Dosage: Type Dosage.
☐Actos/Avandia Select below. Dosage: Type Dosage.
☐Januvia/Onglyza/Tradjenta Select below. Dosage: Type Dosage.
☐Byetta/Victoza/Bydureon Select below. Dosage: Type Dosage.
☐Invokana/Farxiga/Jardiance Select below. Dosage: Type Dosage.
☐Lantus/Levemir insulin Select below. Dosage: Type Dosage.
☐NPH insulin Select below. Dosage: Type Dosage.
☐Novolog/Humalog/Apidra/Regular Select below. Dosage: Type Dosage.
☐70/30-75/25-50/50 insulin Select below. Dosage: Type Dosage.
Have you ever seen an RN or RD for diabetes? Select below. If yes, when/where? Type Date/Place.
Have you ever been hospitalized for diabetes? Select below. If yes, when? Type Date.
Do you have severe episodes of low blood sugar? Select below. If so, how often? Enter text.
Do you have mild episodes of low blood sugar? Select below. If so, how often? Enter text.
What do you treat low blood sugars with? Enter text.
Do you have Ketostix at home? Select below. If so, do you know how and when to use? Select below.
Do you wear medical identification? Select below.
Do you have Glucagon? Select below. If yes, does someone know how and when to use? Select below.
Do you know how to manage sick days? Select below. Do you alter med doses when sick? Select below.
What meter do you use? enter text. When do you test your blood? enter text.
COMPLICATIONS FROM DIABETES
Have you had, do you currently have, or ever been told you have/had:
☐Cataracts or cataract surgery ☐ Retinopathy or blood vessel changes in your eyes
Last eye exam? Enter date. ☐Nephropathy or protein in your urine
☐Neuropathy or foot numbness/burning/erectile dysfunction
☐Heart disease, heart attack or stroke If yes, when?: Enter date.
MEDICAL HISTORY
Major surgeries: Enter text.
Chronic or major medical problems? Enter text.
DIET & SCHEDULE
Are you on a special diet? Enter text.
Times you eat meals: Enter times.
Time you take meds/insulin: Enter time.
What time do you wake up? Enter time. What time do you go to bed? Enter time.
How often do you eat out? Enter text.
What is the biggest problem with your diet? Enter text.
Would you like to see a dietitian? Select below.
FAMILY MEDICAL HISTORY
Does anyone in your family have:
☐ Diabetes ☐High blood pressure
☐ Thyroid disease
☐High cholesterol
☐History of stroke
☐Heart problems
PERSONAL HISTORY
Marital status: Choose an item. Allergies: Click here to enter text.
Do you smoke? Select below. If yes, how much: Click here to enter text.
Do you drink alcohol? Select below. If yes, how much: Click here to enter text.
Do you use recreational drugs? Select below.
Exercise? Select below. Activity Type(s): Click here to enter text. How often? Click here to enter text.
How long? Click here to enter text.
Employed? Select below. Where? Click here to enter text. Hours work per week: Click here to enter text.
Children and their health status: Click here to enter text.
Current Medication List: Click here to enter text.
REVIEW OF SYSTEMS
Are you currently having problems with:
Constitutional: ☐Change in appetite (increase or decrease) ☐weight loss or gain ☐fever
Comments: Click here to enter text.
Neurological: ☐Stroke ☐seizures ☐headaches ☐dizziness ☐tremors ☐numbness/tingling in
feet/hands
Comments: Click here to enter text.
Eyes: ☐Double vision ☐blurry vision
Comments: Click here to enter text.
Ears, Nose, Throat: ☐Sore throat ☐change in voice quality
Comments: Click here to enter text.
Cardiovascular: ☐Chest pain ☐Palpitations ☐Pain in legs when walking ☐Ankle swelling
Comments: Click here to enter text.
Respiratory: ☐Short of breath ☐Cough ☐Wheezing
Comments: Click here to enter text.
Gastrointestinal: ☐Diarrhea ☐Constipation ☐Nausea ☐Vomiting ☐Heartburn ☐Dark/bloody stools
Comments: Click here to enter text.
Genitourinary: ☐Sexual problems (libido, erections) ☐Frequent or painful urination
Comments: Click here to enter text.
Musculoskeletal: ☐Fractures ☐Muscle weakness ☐Joint discomfort
Comments: Click here to enter text.
Feet: ☐Pain ☐Discoloration ☐Decreased sensation ☐Deformities ☐Other problems
Comments: Click here to enter text.
Skin/Hair: ☐Rash ☐Itching ☐Change in pigmentation ☐Easy bruising ☐Excessive sweating
Comments: Click here to enter text.
Psychiatric: ☐Depression ☐Anxiety
Comments: Click here to enter text.
General/Endocrine: ☐Excessive thirst ☐Fatigue ☐Sleep Disturbance ☐Snoring
Comments: Click here to enter text.
Please bring this entire form with you to your appointment, along with your meter (if you do not
have one, Roxie will supply one for you), blood sugar record sheet, and medication list or meds.