PATIENT IDENTIFICATION
Healthplex at 1268 Lee Blvd
Richland, WA 99352
Phone: 942-2660
HYPOGLYCEMIA ASSESSMENT
_____________________________
Last Name
_______________________
First Name
______  Male  Female ____________________
M.I.
Date of Birth
Height: _______Weight: _______Goal Weight: ________ How has your weight changed over the past year? ________________
*Race:  Caucasian  African American  Hispanic  Native American  Asian
 Other : _________________
* Information requested by the American Diabetes Association for statistical purposes
Language:
 English
 Other: __________________________
Interpreter Needed?  Yes
 No
Highest Level of Education: ________________________________________________________________________________
Occupation:
Title _________________________ Employer ________________________ Working hours ______________
 Yes
Do you live alone?
 No
Primary support person ___________________________________________
Do you have any concerns for your safety in the home?  Yes  No If yes, explain _________________________________
Does anyone in your family have diabetes?
 Yes  No
Who? _____________________________________
Have you had nutrition education in the past?
 Yes  No
When? ____________________________________
Where? _______________________________________________
 Yes
Do you have difficulty obtaining supplies or medications?
 Cost
If yes, is the difficulty related to:
Educator? ______________________________________
 No
 Transportation
 Other: ______________________
HEALTH HISTORY
Primary Physician: ___________________________
Other physicians/problems treated: ____________________________
Known Adverse & Allergic Reactions (identify type of reaction)
Known Significant Medical Diagnoses/Conditions
Dx/Conditions
Onset
Date
Dx/Conditions
Onset
Date
Dx/Conditions
Onset
Date
Onset
Date
Dx/Conditions
Heart Disease
Respiratory
Cancer
Back/Neck pain
Chest Pain
Sleep Apnea
Cataracts
Infectious Disease
Heart Attack
Thyroid
Glaucoma
Implants/prosthesis
Pacemaker
Stroke
GI/Liver
Psych Hx/Depression
Hypertension
Seizures
Kidney
Metal in Body
Rheumatic
Fever
Neuro
Other:
Pregnancy
Due Date:
No. Pregnancies:
Medicine/Prenatal vitamins:
No. Children/Ages:
0 7 6 5
1 of 4
Date: 05/22/14
MEDICATIONS: (Prescriptions, including insulin, oral diabetes
medications, inhalers and eye drops, over the counter drugs
like aspirin and ibuprofen products)
Taking No Medications
Unable to obtain
medication history. Reason
___________________________________
Name of Prescribed Medication
PATIENT IDENTIFICATION
Dose
Frequency
Last Dose/Comments
Over the Counter Medications
Dose
Frequency
Last Dose/Comments
Vitamins, Minerals & Herbals
Dose
Frequency
Last Dose/Comments
Known Significant Operative & Invasive Procedures/or Treatment History:
Date
Date
Date
Date
Date
Date
-------------------------------------------------------------------------------------------------------------------------------------------------------Staff Use Only – Reviewed By:
Print Name & Title _______________________________________________ Date of Entry ___________________________
Print Name & Title _______________________________________________ Date of Entry ________________________
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Date: 05/22/14
Are you considering pregnancy?
 Yes
 No
Have you smoked or used tobacco in the last 12 months?
 Yes
 No
If yes, how much per
PATIENT IDENTIFICATION
day? _________________
What kind?
 Cigarettes  Cigars  Chewing tobacco Other: _________________________________________
Would you like information on quitting or help maintaining your smoke-free status?
Do you drink alcohol?
 Yes
 No
 Yes
 No
If yes, how much per day? _________________ Per week? ________________
When was your last complete physical? ____________________________
By whom? ________________________________
When was your last eye exam? ___________________________________
By whom? ________________________________
When was your last dental exam? _________________________________
By whom? ________________________________
MONITORING: Do you check your blood sugar at home?  Yes
How often do you check your blood sugar?
 No
Times per day __________________
 I don’t have a meter
Times per week ____________________
What meter do you use? _____________________What is your blood sugar goal (what would you like it to be?)_____________
 Yes
Do you keep a record of your test results?
 No
HYPOGLYCEMIA (low blood sugar): How long have you had hypoglycemia or low blood sugar? ______________________
Does anyone in your family have hypoglycemia?
 Yes
 No
Are you currently experiencing any of the following?
 No
 Yes (if answer is yes, continue below)
 Sweating
 Shaking
 Feeling of tiredness or weakness
 Dizziness
 Changes in appetite or weight
Who? ___________________________
 Blurred vision
 Fast heart rate
When do you feel these symptoms? ______________________________________________________________________________________
What do you eat or drink for low blood sugar? __________________________ Do you carry this with you?
 Yes
Do you wear a medical alert bracelet or necklace or carry an ID card?
 No
Have you been to the emergency room, urgent care or hospital for your hypoglycemia in the last year?
 Yes
Have you ever passed out from low blood sugar?
 Yes
Do you own a glucagons emergency kit?
 No
 Yes  No
 Yes
 No
If yes, when was the last time? ________________
 No
NUTRITION MANAGEMENT: Do you follow any particular nutrition or meal plan?
 Yes
 No
If yes, what is it? _____________________________________ How much of the time do you follow it? ___________________
Do you follow any of these food restrictions?
 Calorie restriction
 Low sodium
 Low fat
 High potassium
 Low protein
 Low potassium
Other: ___________________
How many meals do you usually eat per day? ___________________________________________________________________
Do you eat planned snacks?
 Yes  No If yes, what and when? ______________________________________
How many times a week do you: Skip or  Delay a meal or snack? Meals__________________ Snacks ________________
How many times a week do you eat away from home? _________ Where? ___________________________________________
Do you ever binge (eat uncontrollably)?
 Yes  No
If yes, how often? _______________________________
How do mood changes or stress affect your eating? ______________________________________________________________
Who usually shops for food? _______________________________
Who usually prepares your food? ___________________
Do you require financial assistance in purchasing food? __________________________________________________________
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Date: 05/22/14
FOOD RECALL (Describe your typical eating habits): List all
foods eaten in a typical day and the approximate time you
have each meal or snack. Include the specific amount and
PATIENT IDENTIFICATION
how it is prepared (fried, broiled, baked, etc.):
Breakfast
Time:
Lunch
Time:
Dinner
Time:
Mid-morning Snack
Time:
Mid-afternoon Snack
Time:
Bedtime Snack
Time:
EXERCISE: How often do you exercise per week? ______________ What time of day do you exercise? __________________
How long do you exercise each time? ___________What kind of exercise do you do? __________________________________
Do you get out of breath or sweaty during exercise?
 Yes
 No
Do you get pains in your legs while walking or during exercise?
 Yes
 No
Has your physician told you to limit exercise in any way?
 Yes
 No
PAIN ASSESSMENT: Do you have pain?  Yes  No
Is the pain controlled?  Yes  No
Rate pain level on a scale of 1 to 10 (with 10 as the worst): ____________
Location of pain __________________________________ When did it start? _______________________________
What causes pain? ________________________________ What relieves pain? _________________________ _____
EMOTIONAL ASPECTS OF ILLNESS:
Have you been feeling sad or depressed?
 Yes
 No
Are you getting less pleasure from your job, sports, and hobbies?
 Yes
 No
Do you often feel tired?
 Yes
 No
Do you have trouble sleeping?
 Yes
 No
Do you sleep too much?
 Yes
 No
Do you often feel agitated, anxious, nervous or stressed?
 Yes
 No
Do you have trouble making decisions or concentrating on your work?
 Yes
 No
Do you often feel down on yourself, that everything is your fault?
 Yes
 No
Do you ever feel that life isn’t worth living?
 Yes
 No
Circle any words that describe how you currently feel about your hypoglycemia and how it affects you:
Overwhelmed
Out of control
Hassled
Burdened
Alone
Angry
What is you greatest fear about having hypoglycemia? ____________________________________________________________
Please list the three things that you most want to learn about how you take care of your low blood sugar:
1.
____________________________________________________________________________________________________
2.
____________________________________________________________________________________________________
3.
____________________________________________________________________________________________________
__________________________________________________
__________________________________________________
Patient’s Signature
Educator’s Signature
#0765
Date/Time
Date/Time
4 of 4
Date: 05/22/14