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<h1>Toolkit for Implementing the Chronic Care Model in an Academic Environment</h1>
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<h2>Diabetes Pre-Visit Questionnaire</h2>
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<h3>Table of Contents</h3>
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<ul>
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<li><a href="/prevention/curriculum/chroniccaremodel/index.html">Toolkit for Implementing the Chronic Care Model in an Academic Environment</a></li>
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<li><a href="/prevention/curriculum/chroniccaremodel/chronicack.html">Acknowledgments</a></li>
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<li><a href="/prevention/curriculum/chroniccaremodel/chroniccare1.html">1. Engaging Leadership</a></li>
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<li><a href="/prevention/curriculum/chroniccaremodel/chroniccare2.html">2. Harnessing the Academic Culture</a></li> <li><a href="/prevention/curriculum/chroniccaremodel/chroniccare3.html">3. Implementing the Chronic Care Model into Practice</a></li><li>
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<a href="/prevention/curriculum/chroniccaremodel/chroniccare4.html">4. Health Professions Education for Chronic Care</a></li> <li> <a href="/prevention/curriculum/chroniccaremodel/chronicgloss.html">Glossary</a></li> </ul>
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<article role="article" about="/prevention/curriculum/chroniccaremodel/chronic3a13d.html" class="node node--type-ahrq-publication node--view-mode-full clearfix">
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<div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>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.</p>
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<table border="0" summary="layout"><tbody><tr><td> </td>
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<td align="center"> </td>
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<td><strong>Summa Health System<br /><em>Family Medicine Center of Akron</em></strong></td>
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</tr></tbody></table><h3>Diabetes Pre-Visit Questionnaire</h3>
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<p>Please bring your most recent two weeks of blood sugar readings and this form to your next visit.</p>
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<p>Eye doctor name / Most recent examination _________________________________________________________</p>
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<p>Heart doctor name / Most recent visit ____________________________________________________________</p>
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<p>Foot doctor name / Most recent visit ______________________________________________________________</p>
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<p>Diabetes specialist name / Most recent visit __________________________________________________________</p>
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<p>Current Medications (Name, dose, time taken)</p>
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<table border="0" cellpadding="2" cellspacing="0" width="60%"><tbody><tr><th scope="col">Name</th>
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<th scope="col">Dose, time taken</th>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr><tr><td scope="row">_______________________________________</td>
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<td>__________________________________________</td>
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</tr></tbody></table><p><strong>Insulin Doses</strong></p>
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<table border="1" cellpadding="0" cellspacing="0" width="60%"><tbody><tr valign="top"><th scope="col">(Circle types below)</th>
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<th scope="col">Morning</th>
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<th scope="col">Lunch</th>
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<th scope="col">Dinner</th>
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<th scope="col">Bedtime</th>
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</tr><tr valign="top"><td scope="row">Humulin R Novolin R<br />
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Humalog Novolog</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr><tr><td scope="row">Humulin N Novolin N<br />
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NPH Lente/Ultralente</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr><tr><td scope="row">Lantus</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr><tr><td scope="row">Humulin or Novolin 70/30</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr><tr><td scope="row">Humulin or Novolin 50/50</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr><tr><td scope="row"> </td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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<td>Units ______</td>
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</tr></tbody></table><p><strong>What is the most important thing you hope to get out of your visit today?</strong></p>
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<p>_________________________________________________________________________________________________________________<br /><br />
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_________________________________________________________________________________________________________________</p>
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<p><strong>What concerns you the most about your diabetes?</strong></p>
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<p>_________________________________________________________________________________________________________________<br /><br />
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_________________________________________________________________________________________________________________</p>
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<p><strong>Current Exercise:</strong> List types of exercise __________________________ <br />
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How often do you exercise? ____________________ How long do you usually exercise? __________________<br />
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If you cannot exercise, list the reasons ______________________________________________________________<br /><br />
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_______________________________________________________________________________________________</p>
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<p><strong>List any trips to emergency room, hospital admissions or surgical procedures since your last visit</strong></p>
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<p>_________________________________________________________________________________________________________________<br /><br />
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_________________________________________________________________________________________________________________</p>
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<p><strong>How would you describe your overall health? </strong> Excellent Good Fair Poor</p>
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<p>Please circle yes (Y) or no (N) to the following questions about your current abilities, symptoms and concerns</p>
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<h4>General</h4>
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<table border="0" cellpadding="2" cellspacing="0" width="60%"><tbody><tr><th scope="col">Y/N<br />
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(circle one)</th>
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<th align="left" scope="col">Abilities, symptoms and concerns</th>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I am unable to do household chores</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have missed work due to diabetes</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I am unable to go up and down stairs</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have cut back on social functions (hobbies, church, clubs)</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have trouble with my energy level</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have concerns about my sexual function</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have trouble with sleep</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have trouble affording my medications</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have trouble with concentration</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have trouble managing my medications</td>
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</tr></tbody></table><h4>Diabetes</h4>
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<p>How often do you test your blood sugar? (circle answer) <br /><br />
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Rarely When I feel bad Once a week 1 or 2 times a week Daily Twice daily 4 times daily</p>
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<p>What time do you usually test blood sugar? (circle all that apply)<br /><br />
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Fasting After breakfast Before Lunch After Lunch Before Supper After Supper Before bedtime</p>
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<p>How many times in the last week have you had low blood sugar? ______ How many times in the last month? _____<br />
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What time of day does your low blood sugar occur? _______ <br />
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How do you treat low blood sugar episodes? (Circle) Glucose tablets Juice Fruit Other ___________<br />
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If you are using insulin, do you have a Glucagon kit? Yes/No</p>
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<table border="0" cellpadding="2" cellspacing="0" width="60%"><tbody><tr><th scope="col">Y/N<br />
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(circle one)</th>
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<th align="left" scope="col">Abilities, symptoms and concerns</th>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I am thirsty and drink a lot</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I lose control of my urine and get wet</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I urinate a lot</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have numbness, tingling or pain in my feet and legs</td>
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</tr></tbody></table><h4>Cardiovascular</h4>
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<table border="0" cellpadding="2" cellspacing="0" width="65%"><tbody><tr><th scope="col">Y/N<br />
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(circle one)</th>
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<th align="left" scope="col">Abilities, symptoms and concerns</th>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have chest pain or shortness of breath when I do work, exercise or get upset</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I get shortness of breath that limits my usual activities; Y N I have swelling in my legs</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have pain in my legs that makes me stop when I walk</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have had temporary loss of vision in one eye</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have had temporary loss of strength or coordination in the muscles of my face, arm or leg</td>
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</tr></tbody></table><h4>Emotions/Social</h4>
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<table border="0" cellpadding="2" cellspacing="0" width="60%"><tbody><tr><th scope="col">Y/N<br />
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(circle one)</th>
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<th align="left" scope="col">Abilities, symptoms and concerns</th>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have been down, depressed and hopeless lately</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>I have lost interest in, or no longer enjoy the things I used to enjoy doing</td>
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</tr><tr><td align="center" scope="row">Y N </td>
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<td>Have you had 5 or more drinks at one occasion in the last 3 months?</td>
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</tr></tbody></table><p><strong>I would like more information about</strong> (circle all that apply )</p>
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<p>Eating the right things<br />
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Safe exercise<br />
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Foot care<br />
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Stopping smoking<br />
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What to do if I am sick<br />
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Insulin<br />
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My medications<br />
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Alcohol use and diabetes<br />
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High blood pressure<br />
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Cholesterol</p>
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<p class="size2"><a href="/prevention/curriculum/chroniccaremodel/chronic3a13.html">Return to Document</a></p>
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</article>
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<div class="row">
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<div class="col-md-12 col-sm-12 text-right">
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<section class="row region region-citation">
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<div class="block block-ahrq block-citation">
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<div class="content">
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<div id="created-reviewed-citation" class="pad-bottom-sections">
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<div id="page-reviewed" class="body-copy-italic">Page last reviewed October 2014</div>
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<div id="page-created" class="body-copy-italic">Page originally created January 2008</div>
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</div>
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<div id="citation">
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<div class="twocolordiv">
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<div class="twocolordiv-content">
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<p>
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<span class="citation-hdr">Internet Citation:</span> Diabetes Pre-Visit Questionnaire. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.<br>
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<span class="citation-url">https://archive.ahrq.gov/prevention/curriculum/chroniccaremodel/chronic3a13d.html</span>
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</p></div>
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<div class="citation-flag"> </div> </div> <!--</div>--> <div class="footnote"> <p> The information on this page is archived and provided for reference purposes only.</p> </div> <p> </p> </div> </div></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div>
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