Toolkit for Implementing the Chronic Care Model in an Academic Environment
Diabetes Pre-Visit Questionnaire
Summa Health System developed this questionnaire for patients to complete before a planned visit. The document focuses on key concerns diabetic patients and their care providers face and is used to help the patient make self-management goals and request information on specific health topics, such as high blood pressure and cholesterol levels.
| Summa Health System Family Medicine Center of Akron |
Diabetes Pre-Visit Questionnaire
Please bring your most recent two weeks of blood sugar readings and this form to your next visit.
Eye doctor name / Most recent examination _________________________________________________________
Heart doctor name / Most recent visit ____________________________________________________________
Foot doctor name / Most recent visit ______________________________________________________________
Diabetes specialist name / Most recent visit __________________________________________________________
Current Medications (Name, dose, time taken)
| Name | Dose, time taken |
|---|---|
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
| _______________________________________ | __________________________________________ |
Insulin Doses
| (Circle types below) | Morning | Lunch | Dinner | Bedtime |
|---|---|---|---|---|
| Humulin R Novolin R Humalog Novolog |
Units ______ | Units ______ | Units ______ | Units ______ |
| Humulin N Novolin N NPH Lente/Ultralente |
Units ______ | Units ______ | Units ______ | Units ______ |
| Lantus | Units ______ | Units ______ | Units ______ | Units ______ |
| Humulin or Novolin 70/30 | Units ______ | Units ______ | Units ______ | Units ______ |
| Humulin or Novolin 50/50 | Units ______ | Units ______ | Units ______ | Units ______ |
| Units ______ | Units ______ | Units ______ | Units ______ |
What is the most important thing you hope to get out of your visit today?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
What concerns you the most about your diabetes?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Current Exercise: List types of exercise __________________________
How often do you exercise? ____________________ How long do you usually exercise? __________________
If you cannot exercise, list the reasons ______________________________________________________________
_______________________________________________________________________________________________
List any trips to emergency room, hospital admissions or surgical procedures since your last visit
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
How would you describe your overall health? Excellent Good Fair Poor
Please circle yes (Y) or no (N) to the following questions about your current abilities, symptoms and concerns
General
| Y/N (circle one) |
Abilities, symptoms and concerns |
|---|---|
| Y N | I am unable to do household chores |
| Y N | I have missed work due to diabetes |
| Y N | I am unable to go up and down stairs |
| Y N | I have cut back on social functions (hobbies, church, clubs) |
| Y N | I have trouble with my energy level |
| Y N | I have concerns about my sexual function |
| Y N | I have trouble with sleep |
| Y N | I have trouble affording my medications |
| Y N | I have trouble with concentration |
| Y N | I have trouble managing my medications |
Diabetes
How often do you test your blood sugar? (circle answer)
Rarely When I feel bad Once a week 1 or 2 times a week Daily Twice daily 4 times daily
What time do you usually test blood sugar? (circle all that apply)
Fasting After breakfast Before Lunch After Lunch Before Supper After Supper Before bedtime
How many times in the last week have you had low blood sugar? ______ How many times in the last month? _____
What time of day does your low blood sugar occur? _______
How do you treat low blood sugar episodes? (Circle) Glucose tablets Juice Fruit Other ___________
If you are using insulin, do you have a Glucagon kit? Yes/No
| Y/N (circle one) |
Abilities, symptoms and concerns |
|---|---|
| Y N | I am thirsty and drink a lot |
| Y N | I lose control of my urine and get wet |
| Y N | I urinate a lot |
| Y N | I have numbness, tingling or pain in my feet and legs |
Cardiovascular
| Y/N (circle one) |
Abilities, symptoms and concerns |
|---|---|
| Y N | I have chest pain or shortness of breath when I do work, exercise or get upset |
| Y N | I get shortness of breath that limits my usual activities; Y N I have swelling in my legs |
| Y N | I have pain in my legs that makes me stop when I walk |
| Y N | I have had temporary loss of vision in one eye |
| Y N | I have had temporary loss of strength or coordination in the muscles of my face, arm or leg |
Emotions/Social
| Y/N (circle one) |
Abilities, symptoms and concerns |
|---|---|
| Y N | I have been down, depressed and hopeless lately |
| Y N | I have lost interest in, or no longer enjoy the things I used to enjoy doing |
| Y N | Have you had 5 or more drinks at one occasion in the last 3 months? |
I would like more information about (circle all that apply )
Eating the right things
Safe exercise
Foot care
Stopping smoking
What to do if I am sick
Insulin
My medications
Alcohol use and diabetes
High blood pressure
Cholesterol
5600 Fishers Lane Rockville, MD 20857