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Diabetes Questionnaire
Home
Forms
Diabetes Questionnaire
Diabetes Questionnaire
"
*
" indicates required fields
Name
*
First
Last
Date of Birth
*
Month
Day
Year
1. When was diabetes first diagnosed?
*
2. Please state name and address of doctor you consult regarding your diabetes:
*
3. What treatment do you receive? (e.g. diet, oral drugs, insulin)
*
4. How often do you receive treatment?
*
Elevated Blood Pressure
Yes
No
End Stage Renal Disease
*
Yes
No
Eye Trouble
Yes
No
Heart Trouble
*
Yes
No
Skin Ulcers
*
Yes
No
Kidney Trouble
*
Yes
No
Recurrent Infections
*
Yes
No
Other prolonged illness
*
Yes
No
If Yes to any of these conditions, please explain
6. Have you ever had a diabetes coma?
*
Yes
No
If so please provide dates:
*
7. Have you had time off work due to this?
*
Yes
No
If yes, when and how much?
8. Have you ever undergone any of the following tests:
Electrocardiogram
*
Yes
No
Lipid Profile
*
Yes
No
Chest X-ray
*
Yes
No
Glycosylated Hemoglobin (HbA1c)
*
Yes
No
If Yes, please state the results:
Signature of Client
Signature of Client
Date
*
MM slash DD slash YYYY
Date
Δ