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questionnaire for diabetes General Information: Name: _______________ Date: _________ Gender: ___________ get up up: : ______ social status : ___________ Diabetes History * What type of diabetes do you have? 1) flake 1 2) Type 2 3) gaint slam * For women, did you have gestational diabetes or a baby measure more than 9 pounds? Yes No * each 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 create ver bally 4. an insulin pump read you ever forgotten to take your diabetes practice of medicine? Yes No If yes, what did you do? Monitoring Do you campaign your ancestry glucose ( dulcify)? If yes, how many clock do you test per day? frequent 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? coarse results ________ Acute Complications Have you ever had a low relationship sugar reacti on? Yes N! o How did 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) center of attention 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 approximately recent physical query by primary parcel out provider? How often do you have your eyes check? How often do you check...If you ask to get a spacious essay, order it on our website: OrderCustomPaper.com

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