Diabetes Pre-Visit Questionnaire

Toolkit for Implementing the Chronic Care Model in an Academic Environment

Summa Health System developed this questionnaire for patients to complete before a planned visit. The document focuses on key concerns diabetic patients and their care providers face and is used to help the patient make self-management goals and request information on specific health topics, such as high blood pressure and cholesterol levels.

  Summa Health System
Family Medicine Center of Akron

Diabetes Pre-Visit Questionnaire

Please bring your most recent two weeks of blood sugar readings and this form to your next visit.

Eye doctor name / Most recent examination _________________________________________________________

Heart doctor name / Most recent visit     ____________________________________________________________

Foot doctor name / Most recent visit     ______________________________________________________________

Diabetes specialist name / Most recent visit __________________________________________________________

Current Medications (Name, dose, time taken)

NameDose, time taken
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Insulin Doses
(Circle types below)MorningLunchDinnerBedtime
Humulin R   Novolin R
Humalog      Novolog
Units ______Units ______Units ______Units ______
Humulin N   Novolin N
NPH Lente/Ultralente
Units ______Units ______Units ______Units ______
LantusUnits ______Units ______Units ______Units ______
Humulin or Novolin 70/30Units ______Units ______Units ______Units ______
Humulin or Novolin 50/50Units ______Units ______Units ______Units ______
 Units ______Units ______Units ______Units ______

What is the most important thing you hope to get out of your visit today?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

What concerns you the most about your diabetes?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Current Exercise: List types of exercise __________________________   
How often do you exercise? ____________________   How long do you usually exercise? __________________
If you cannot exercise, list the reasons   ______________________________________________________________

_______________________________________________________________________________________________

List any trips to emergency room, hospital admissions or surgical procedures since your last visit

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

How would you describe your overall health?      Excellent       Good      Fair       Poor

Please circle yes (Y) or no (N) to the following questions about your current abilities, symptoms and concerns

General

Y/N
(circle one)
Abilities, symptoms and concerns
Y  N I am unable to do household chores
Y  N I have missed work due to diabetes
Y  N I am unable to go up and down stairs
Y  N I have cut back on social functions (hobbies, church, clubs)
Y  N I have trouble with my energy level
Y  N I have concerns about my sexual function
Y  N I have trouble with sleep
Y  N I have trouble affording my medications
Y  N I have trouble with concentration
Y  N I have trouble managing my medications

Diabetes

How often do you test your blood sugar? (circle answer) 

Rarely   When I feel bad       Once a week       1 or 2 times a week       Daily      Twice daily     4 times daily

What time do you usually test blood sugar? (circle all that apply)

Fasting    After breakfast    Before Lunch    After Lunch    Before Supper    After Supper   Before bedtime

How many times in the last week have you had low blood sugar? ______  How many times in the last month? _____
What time of day does your low blood sugar occur? _______ 
How do you treat low blood sugar episodes? (Circle)  Glucose tablets   Juice   Fruit    Other ___________
If you are using insulin, do you have a Glucagon kit?   Yes/No

Y/N
(circle one)
Abilities, symptoms and concerns
Y  N I am thirsty and drink a lot
Y  N I lose control of my urine and get wet
Y  N I urinate a lot
Y  N I have numbness, tingling or pain in my feet and legs

Cardiovascular

Y/N
(circle one)
Abilities, symptoms and concerns
Y  N I have chest pain or shortness of breath when I do work, exercise or get upset
Y  N I get shortness of breath that limits my usual activities; Y  N  I have swelling in my legs
Y  N I have pain in my legs that makes me stop when I walk
Y  N I have had temporary loss of vision in one eye
Y  N I have had temporary loss of strength or coordination in the muscles of my face, arm or leg

Emotions/Social

Y/N
(circle one)
Abilities, symptoms and concerns
Y  N I have been down, depressed and hopeless lately
Y  N I have lost interest in, or no longer enjoy the things I used to enjoy doing
Y  N Have you had 5 or more drinks at one occasion in the last 3 months?

I would like more information about (circle all that apply )

Eating the right things
Safe exercise
Foot care
Stopping smoking
What to do if I am sick
Insulin
My medications
Alcohol use and diabetes
High blood pressure
Cholesterol

Return to Document

Current as of January 2008
Internet Citation: Diabetes Pre-Visit Questionnaire: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic3a13d.html