GENERAL DIABETES INFORMATION

What Type of Diabetes Do You Have?

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

Who Else in Your Family Has/Had Diabetes?

What type(s) ?


BLOOD GLUCOSE TESTING

When Do You Test Your Blood Sugars?


DIABETES TREATMENT

Diabetes Medication(s):

If Using Insulin, Please List:

If Using an Insulin Pump, Please List:


NUTRITION & WELLNESS INFORMATION

Who Shops for Food?

Who Prepares Meals?

What Types of Food Do You Generally Eat at Meals?

How Frequently Do You Eat Out?

Are You Confident Reading a Nutrition Label?

Are You Confident in Making Healthy Diet Choices?

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

Do You Use Any of the Following Food Assistance Programs?

If none would you like more info on them?


TODAY’S APPOINTMENT

What Would You Like to Learn About Regarding Your Health?


TEST YOUR KNOWLEDGE! TAKE OUR DIABETES QUIZ

1. Avoiding all types of carbohydrates controls blood sugar.

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

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

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

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

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.

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

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

9. Symptoms of low glucose include:

10. Treatment for low glucose is:

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

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


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