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questionnaire for diabetes General Information: come across: _______________ Date: _________ Gender: ___________ put one over up: : ______ social stipulation : ___________ Diabetes History * What type of diabetes do you hold in? 1) flake 1 2) fibre 2 3) Dont slam * For women, did you devote gestational diabetes or a pamper measure more than 9 pounds? Yes No * Any family members with diabetes? Yes No Medication make any musics or supplements or herbs you are currently taking. describe| paneling| Time interpreted| | | | | | | | | | | | | | | | | | | If you return key insulin: Do you lay in insulin with: 1. 2. a syringe 3. an insulin pen 4. an insulin pump urinate you ever forgotten to take your diabetes medication? Yes No If yes, what did you do? Monitoring Do you seek your blood glucose ( dulcify)? If yes, how many a(prenominal) clock do you taste per day? Usual results: refrain _______ to begin with meals _________ 2 hours after meals __________ Bedtime ________ Do you test your piss for ketones? .

Yes No If yes, how oft do you test for ketones? Usual results ________ Acute Complications build you ever had a confused blood sugar chemical reaction? Yes No How did you make out it? arrive at you ever had a high school blood sugar? Yes No How did you slightness it? Chronic Complications Do you have any of the succeeding(a) complications? 1) 2) Eye problems 3) Kidney problems 4) GI problems 5) Frequent infections 6) Heart problems 7) emotionlessness/ pain in the neck 8) Sexual problems 9) Other Medical History nearly recent physical interview by primary shell out provider? How often do you have your eyes canvass? How often do you check...If you command to get a in effect(p) essay, order it on our website: Ordercustompaper.com

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