AutoRemind

Today's Date:

Full Name:

Preferred Name:

Date of Birth (DOB):

What Type of Diabetes Do You Have?

Type 1

Type 2

Gestational

Prediabetes

LADA

MODY

Do Not Know

Have You Ever Been Admitted to the Hospital Due to Diabetes?

Yes

No

If Yes, Provide Date(s), Reason(s) for Admission, and Length(s) of Stay:

Who Else in Your Family Has/Had Diabetes?

Mother

Father

Sibling(s)

Maternal Grandparent(s)

Paternal Grandparent(s)

None

Other

What type(s) ?

Type 1

Type 2

Gestational

Prediabetes

LADA

MODY

Do Not Know

When was Your Most Recent HgA1C? What was the Result?

Blood Glucose Testing

I Do NOT Have a Blood Sugar Monitor (Glucometer)

I Do Have a Blood Sugar Monitor (Glucometer)

I Use a Continuous Glucose Monitor (CGM)

Name of Glucometer or CGM:

When Do You Test Your Blood Sugars?

After Waking, Before Breakfast

Ranges:

Before Meals

Minutes Before:

Ranges:

After Meals

Hours After:

Ranges:

Before Bedtime

Ranges:

Other

What are Your Blood Sugar Goal Ranges?

Diabetes Treatment

Diabetes Medication(s):

Pills

Name(s):

Dosage(s):

Frequency:

Non-Insulin Injectables

Name(s):

Dosage(s):

Frequency:

Insulin Vial/Syringe

Insulin Pen

Insulin Pump

None

If Using Insulin, Please List:

Name/Type of Insulin:

Number of Units:

Time Taken:

Name/Type of Insulin:

Number of Units:

Time Taken:

Name/Type of Insulin:

Number of Units:

Time Taken:

Name/Type of Insulin:

Number of Units:

Time Taken:

If Using an Insulin Pump, Please List:

Basal Rate(s):

Insulin to Carb Ratio(s):

Correction Factor (Insulin Sensitivity):

Target Blood Sugar:

Make/Model of Pump:

Nutrition & Wellness Information

Current Height:

Current Weight:

Pre-Pregnancy Weight:

Who Shops for Food?

Self

Other

Who Prepares Meals?

Self

Other

What Types of Food Do You Generally Eat at Meals?

Breakfast:

Lunch:

Dinner:

Snacks:

How Frequently Do You Eat Out?

1-2 Times/Month

1-2 Times/Week

3-4 Times/Week

Daily

What are Your Favorite Places to Eat?

Do You Have Any Food Allergies, Restrictions, or GI Issues?

What is Your Biggest Challenge to Eating Healthy with Diabetes?

Are You Confident in Reading a Nutrition Label?

Yes

No

Would Like Info

Are You Confident in Making Healthy Diet Choices?

Very

Somewhat

Not At All

Was it Ever Difficult to Buy Enough Food in the Past 12 Months?

Yes

No

Do You Use Any of the Following Food Assistance Programs?

WIC

Food Stamps

Meals on Wheels

Food Pantry

Community Meals

None

If None, Would You Like More Info on Them?

Yes

No

What Physical Activity/Exercise Do You Do Regularly?

How Many Days Per Week?

How Many Minutes Per Session?

Do You Have Any Barriers/Challenges to Physical Activity/Exercise?

Today's Appointment

What Questions/Concerns Do You Have Today?

What Would You Like to Learn About Regarding Your Health?

Diabetes in Pregnancy and Treatment Options

Potential Complications of Diabetes in Pregnancy

Lab Interpretation/Goals

Healthy Eating

Being Active

Medications

Monitoring Glucose

Lifestyle and Healthy Coping

Other

What Are Your Goals for Today's Appointment?

Is There Anything Else You Would Like Your Provider to Know?

Test your knowledge! Take our Diabetes Quiz.

1. Avoiding all types of carbohydrates controls blood sugar.

True

False

2. Which food groups contain carbohydrates? (Check all that apply.)

Dairy

Fruit

Vegetables

Grain/Starch

Protein

3. Women with gestational diabetes should be screened for type 2 diabetes every year after pregnancy.

True

False

4. Some women with gestational diabetes will need insulin to keep their blood sugar in the recommended ranges.

True

False

5. Eating for better health includes all the following except:

Eating fruits and vegetables

Avoiding all foods with carbs

Understanding and choosing appropriate portion sizes

Eating when hungry and stopping when satisfied

I do not know

6. I will need to test my blood sugar with a home monitor each day during pregnancy to make sure my blood sugar stays in a safe range.

True

False

7. Which of the following is a way to practice eating mindfully?

Take 15-30 minutes to eat slowly and enjoy your food

Eat at a table

Use a hunger scale to help guide when to eat and when to stop

All of the above

I do not know

8. How does physical activity usually affect your glucose level?

Lowers your glucose level

Raises your glucose level

Has little effect on your glucose level

None of the above

I do not know

9. Symptoms of low glucose include:

Feeling shaky or sweaty

Dry skin

Feeling energetic

Dry mouth

I do not know

10. Treatment for low glucose is:

1 half cup of orange juice

1 can of regular soft drink

1 full-size candy bar

1 ounce of peanuts

I do not know

11. Illness and emotional stress often cause your glucose level to do which of the following?

Rise

Fall

Stay the same

None of the above

I do not know

12. Preconception care and planning is very important for patients with diabetes.

True

False

I attest that the above information is truthful and accurate, to the best of my knowledge. By using an electronic signature, I acknowledge my acceptance of the information above. My electronic signature is as legally binding as my handwritten signature.

Patient or Guardian (where applicable) Printed Name:

Date:

Patient or Guardian (where applicable) Signature:

Please sign electronically below.

Diabetes Intake Form

Blood Glucose Testing

Diabetes Treatment

Nutrition & Wellness Information

Today's Appointment

Test your knowledge! Take our Diabetes Quiz.

Patient or Guardian (where applicable) Signature: