DCH DIABETES AND ENDOCRINOLOGY
Phone: 812-254-2250
1402 GRAND AVENUE
Fax: 812-254-7884
WASHINGTON, IN 47501
1ST. VISIT QUESTIONNAIRE
PLEASE COMPLETE
Name: ____________________________________
DOB: ______________________
Family Provider: ______________________________________________
Phone Number: ___________________
OK to send them a letter? _____Yes
Appointment Date: _____________________
_____No
Referring Provider: ___________________________________________
Phone Number: ___________________
Reason for Visit: _____Diabetes Management
_____Thyroid Problem
_____Other: ___________________________________________________________________
If Diabetes:
Date of Diagnosis: _______________________________________
Ever had formal Diabetes Education? _____Yes
_____No
If yes, where? _______________________
Do you have a meter? _____Yes _____No What Kind? ___________________________________
Do you have an insulin pump? _____Yes _____No
What Kind? _____________________________
Date of last eye exam__________________________
Pharmacy ___________________________________
Doctor Name ___________________________
Mail Order Pharmacy __________________________________
Past History
Yes
No
Past Medical Problems:
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Diabetes
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Thyroid Problem
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High Blood Pressure
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Cataracts
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Glaucoma
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Heart Attack
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Stroke
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High Cholesterol
Other: ____________________________________________________________________________________________
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Surgical History: List Type and Date ____________________________________________________________________
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MEDICATIONS
Over the Counter Meds: Aspirin _____Yes _____No
Multivitamin _____Yes _____No
Other OTC Medications: ______________________________________________________________________________
Prescription Medications:
Name of Medicine
Dose
How Often
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ALLERGIES
_____No Known Medicine Allergies
_____No Known Food or Environmental Allergies
If allergic, list allergies and type of reaction: _____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SOCIAL HISTORY
____Single
____Married
____Divorced
____Widow
Lives with: ________________________
Work: ____________________________
Smoker: ___Yes
____Former Smoker
____No
Alcohol Use: ____Yes ____No
How much:
Name: _________________________________________
____No
____Never Smoker
____Occasional
Flu Shot: ____Yes ____No When:______________
Retired: ____Yes
____Moderate
Pneumonia: ____Yes ____No
____Heavy
When: ____________________
DOB: _____________________________________
FAMILY HISTORY
YES
NO
WHO
___
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Diabetes
____________________________________________________
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Heart Disease
____________________________________________________
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Stroke
____________________________________________________
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High Blood Pressure
____________________________________________________
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High Cholesterol
____________________________________________________
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Thyroid Disease
____________________________________________________
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Cancer-Type-___________
____________________________________________________
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Other _________________
____________________________________________________
DO YOU HAVE:
YES
NO
HOW LONG
YES
NO
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Fever
___
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HOW LONG
_______________
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Wt. Loss # _____
______________
Headaches
_______________
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Wt. Gain # _____
______________
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Blurred Vision
_______________
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Irritability
______________
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Double Vision
_______________
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Tremors
______________
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___ Passing Out Episode _______________
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Sweating
______________
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___Shortness of Breath
_______________
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Hot Flashes
______________
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Dizziness
_______________
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Vaginal Discharge
______________
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Dry Mouth
_______________
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Too Hot
______________
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Thirst
_______________
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Too Cold
______________
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___ Increase Urination _______________
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Snoring
______________
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___Burning Upon Urination______________
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Night Time Urination
______________
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Nausea
_______________
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Increase Facial Hair
______________
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Vomiting
_______________
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Hair Loss
______________
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Bloating
_______________
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Other
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Diarrhea
_______________
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Constipation
_______________
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Swelling
_______________
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Pain in Feet
_______________
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___ Numbness in Hands _______________
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___ Numbness in Feet
For Office Use Only
Date Reviewed: _____________________
Provider Signature: __________________________________
_______________
Name: ______________________________________________
DOB: ______________________________