Poorly controlled diabetes questionnaire

advertisement
Name
How long has patient had Diabetes for?
What is the patient’s ethnicity?
Is there a family history of diabetes?
Does the patient work? What hours
Who manages their Diabetes ?
Does the patient see a regular doctor /
nurse in the practice? If so then who?
What different medications has the
patient been on?
Is the patient on maximum tolerated
therapy ?
Is compliance good? Does the patient
understand what they are taking ?
How many different medications does
the patient take in a day?
Does the patient ever have difficulties
remembering what they have to take?
Is the patient cared for? Do the carers
know what diabetes is about?
What is the Body Mass Index ?
Does the patient ever miss
appointments ?
What complications does the patient
have?
Does the patient have other comorbidities?
Is the patient depressed? How has it
been treated?
Is the patient on the internet? Does the
patient wish to sign up for Records
Access?
Has the patient tried the UKPDS Risk
Engine?
Does the patient smoke?
What successes has the patient had to
change their lifestyle ever?
Families help families. Is there
somebody who can help them with
their diabetes ?
Does the patient monitor any aspect of
their health ?
Does the patient have a smartphone?
What goals does the patient have?
Date
Years
Latest HbA1c
Better / Same / Worse
Parents / Brothers / Sisters / Children / Uncles / Aunties
Yes – full time / part-time / shift work
No
Practice / Diabetes Specialist Nurses / Hospital
Doctor
Nurse
Metformin / Sulphonylureas / Glitazones / Byetta / Insulin /
Other:
Yes
No
Yes
No
Yes
No
Yes
No
>50
<50
Never / Occasionally / Sometimes / Often / Always
Why?
Retinopathy / Autonomic Neuropathy / Peripheral Neuropathy
/ Peripheral Vascular Disease / IHD / Nephropathy
Yes
No
Yes
No
Yes
No
Smoker / Ex-smoker / Non-smoker
Blood Pressure / Weight / Blood sugar
Download