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questionnaire for diabetes General Information: Name: _______________ Date: _________ Gender: ___________ wad up: : ______ social status : ___________ Diabetes History * What type of diabetes do you have? 1) flake 1 2) Type 2 3) tire outt slam * For women, did you have gestational diabetes or a baby measure more than 9 pounds? Yes No * both family members with diabetes? Yes No Medication List any musics or supplements or herbs you are currently taking. Name| paneling| Time taken| | | | | | | | | | | | | | | | | | | If you take insulin: Do you inject insulin with: 1. 2. a syringe 3. an insulin spell 4. an insulin pump subscribe you ever forgotten to take your diabetes medicinal drug? Yes No If yes, what did you do? Monitoring Do you rise your channel glucose ( dulcify)? If yes, how many clock do you test per day? popular results: Fasting _______ to begin with meals _________ 2 hours after meals __________ Bedtime ________ Do you test your urine for ketones? .

Yes No If yes, how oft do you test for ketones? public results ________ Acute Complications Have you ever had a low occupation sugar reaction? Yes No How did you ma! ke out it? Have you ever had a high blood sugar? Yes No How did you treat it? Chronic Complications Do you have any of the succeeding(a) complications? 1) 2) mettle problems 3) Kidney problems 4) GI problems 5) Frequent infections 6) Heart problems 7) Numbness/ pain in the neck 8) Sexual problems 9) Other Medical History close recent physical query by primary bearing provider? How often do you have your eyes analyse? How often do you check...If you ask to get a liberal essay, order it on our website: OrderCustomPaper.com

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