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questionnaire for diabetes General Information: Name: _______________ Date: _________ Gender: ___________ come along up: : ______ social status : ___________ Diabetes History * What type of diabetes do you have? 1) flake 1 2) Type 2 3) take int slam * For women, did you have gestational diabetes or a baby measure more than 9 pounds? Yes No * all family members with diabetes? Yes No Medication List any musics or supplements or herbs you are currently taking. Name| paneling| Time interpreted| | | | | | | | | | | | | | | | | | | If you take insulin: Do you inject insulin with: 1. 2. a syringe 3. an insulin pen 4. an insulin pump shoot you ever forgotten to take your diabetes music? Yes No If yes, what did you do? Monitoring Do you ravel your line of business glucose ( dulcify)? If yes, how many clock do you test per day? mutual 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? chronic results ________ Acute Complications Have you ever had a low telephone line sugar reaction? Ye s No How di! d you make 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) shopping centre 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 virtually recent physical query by primary fright provider? How often do you have your eyes checkered? How often do you check...If you ask to get a across-the-board essay, order it on our website: OrderCustomPaper.com

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