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Diabetes Questionnaire
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Forms
Diabetes Questionnaire
Diabetes Questionnaire
"
*
" indicates required fields
URL
This field is for validation purposes and should be left unchanged.
Name
*
First
Middle
Last
Date of Birth
*
1. Please state name and address of doctor you consult regarding your diabetes:
Doctor's Name
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Doctor's Address
Street Address
City
State / Province / Region
2. When was diabetes first diagnosed?
3. What treatment do you receive?
*
4. How often do you receive treatment?
*
5. Have you suffered from any of the following?
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
7. Have you had time off work due to this?
*
Yes
No
If so please provide dates:
*
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:
Date
*
Date
Signature of Client
*
Signature of Client
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