Appointment Date
Baylor Health Care System
Diabetes Education
Appointment Time
PATIENT FORM FOR FIRST VISIT
Name: _______________________
Date of Birth: _________________
Gender:
 Female  Male
Month/Day/Year
Preferred Contact #: _______________
(is this  home  cell, or a  work #?)
or email: ________________________
Your Medical History
Diabetes When were you diagnosed? ________________
Foot Ulcer/Infection
History of Stroke
Kidney Disease
Polycystic Ovary Syndrome
Congestive Heart Failure
Dialysis
Gastrointestinal Problems
Heart Disease
Liver Disease
Celiac Disease
High Blood Pressure
Nerve Disease
Gastric Reflux
Heart Attack
Eye Disease
Sexual Dysfunction
High Cholesterol
History of organ transplant
Other:
History of weight loss surgery
Obesity
Skin Problems
Thyroid Disease
Depression
Sleep Apnea
Snoring
Medications, over-the-counter drugs, vitamins and supplements (you may attach a copy of your medication list)
Drug Name:
Dose:
When do you take it:
1.
2.
3.
4.
5.
6.
7.
8.
List insulin dosages and times you take it /include sliding scale if you use one
How do you take your insulin?
Syringe
Insulin Pen Type:
Insulin Pump Type:
Other:
When did you start using insulin?
How often do you miss taking your
diabetes medications?
Never/Rarely
1 time per week
2-3 times per week
4-6 times per week
More than 7 times per week
Where do you inject your insulin?
Abdomen
Arm
Buttocks
Thighs
Other:
What keeps you from taking your
medications? Check all that apply
Memory
Finances
Dosage
Regimen too Complex
Fear of Side Effects
Don’t Need It
BHCS Diabetes Education 2013
1
Do you adjust your dose of insulin?
No
Yes
Do you have glucagon available?
No
Yes
Do you have any allergies to medications?
No
Yes
List below:
Number of hours
Occupation
worked per week
Manual Labor
Less than 20
Professional
20 to 40
Retired
More than 40
Unemployed
NA
Other:
What do you do for a living?
How do you like to
learn about diabetes?
(choose ONLY 1)
Do you have any
problems learning new
things?
Reading
Lecture
Hands On
Video/DVD
Have you ever had hyperglycemia
(glucose greater than 180 mg/dl)?
Yes
No
If yes, how often does it happen?
1 - 3 times per week
4 - 6 times per week
More than 7 times per week
Rarely
Unknown
Do you check your blood
glucose (blood sugar)?
Yes
No
Less than
high school
High
school/GED
How often do you check?
Do you skip meals?
Yes
No
Who prepares your food?
Self
Spouse
Both
Other:
How often do you eat out?
Daily
4 to 6 times per week
1 to 3 times per week
Every other week
Occasionally
Rarely
Never
Family
Other
Do you have a
family
history of diabetes?
Mother
Father
Brother/Sister
Grandparent
Unknown
None
Most recent weight?
Date:
Most recent height?
Date:
What is the name of your meter?
More than 4 times daily
Every other day
Occasionally
Rarely/never
No
No
No
No
No
No
No
Significant other
In the past year
1-2 yrs ago
3-5 yrs ago
Not sure
Have you ever had hypoglycemia
(glucose less than 70 mg/dl)?
Yes
No
How often does it happen?
1 - 3 times per week
4 - 6 times per week
More than 7 times per week
Rarely
Unknown
Have you had any of the following in the past year?
Foot Exam by a health care professional?
Yes
Dilated Eye Exam
Yes
ECG/Stress Test
Yes
Pneumonia Vaccine
Yes
Dental Exam
Yes
Flu Vaccine
Yes
Weight Loss Surgery
Yes
With whom do
you live?
Self
Spouse
No
Yes
College
1 time daily
2 times daily
3 times daily
4 times daily
Who is responsible
for your care?
Self
Spouse
Significant other
Family
Other
Have you had diabetes education
in the past?
Education
None
Vision
Hard of Hearing
Language
Reading is Hard
Other
Group
Discussion
Who is your main
support person?
Self
Spouse
Significant other
Family
Other
Shift
Days
Evening
Night
Rotating
NA
Do you use any other sites than your fingers to check
your blood glucose?
Yes
No
Do you drink alcohol?
Do you smoke or use tobacco products?
Yes
No
Yes
No
How much?
How much?
Less than one daily
less than 5 per day
½ pack per day
1-2 daily
1 pack per day
1+pack per day
3 or more daily
Occasionally
Do you use recreational drugs?
Yes
No
Do you carry diabetes identification with you?
Yes
No
Do you follow a special diet?
No
Yes, List:
Do you have any food intolerance or allergies?
No
Yes, List
Cultural/Religious dietary needs?
No
Yes, List:
BHCS Diabetes Education 2013
2
Do you exercise?
Yes, check type of exercise
Aerobic (walking, swimming, biking etc.)
Strength Training (lifting weights)
No
Do you have any physical limitations? Please list:
Do you exercise at least 150 minutes /week?
No
Rate your knowledge of
diabetes:
Yes
How many times in a week?
How do you feel about having diabetes? Choose ONE:
Acceptance
Denial
Fear
Guilt
less than 1/week
5 to 6/week
Good
Adjusting
Anger
1 to 2/ week
7 or more/week
Fair
Overwhelmed/Confused/Frustration
Poor
Sadness/Depression
3 to 4/week
How is your general health?
Good
Fair
Poor
How is your stress level?
High
Medium
Low
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Diabetes interferes with?
Check all the apply
Nothing
Family/Social Activities
Work/School
Sports/Exercise
Sexual Relations
Finances
Travel
Other:
Do you examine your feet?
Yes
No
How Often?
Daily
Every other day
Occasionally
Rarely
For Women Only
Are you having periods?
Are you post-menopausal?
Are you using birth control?
Are you currently pregnant?
Have you had a baby that weighed 9 lbs. or greater?
Have you ever had Gestational Diabetes?
Have you had any complications with past pregnancies?
Are you considering pregnancy?
Is there anything else you would like to let your diabetes educator know?
BHCS Diabetes Education 2013
3
Do you have any foot problems?
Check all that apply
None
Callus(es)
Bunions
Neuropathy
Ulcer
Fungal Toenail(s)
Structural Deformity
Other:
If you are pregnant:
How many weeks pregnant are you?
When is your due date?
How much did you weigh before you got pregnant?
Baylor Health Care System
Nutrition/Food Questionnaire
Please list food you usually have in a 24 hours period.
Breakfast (Time):_______
Lunch (Time):__________
Evening (Time):________
AM Snack
(Time):________
Afternoon Snack
(Time): _______
Bedtime Snack (Time):_______
Your work schedule (Ex: M-F 8-5:00pm) (if applicable) ______________________________
Your usual wake-up time:___________________
Your usual bedtime:______________
Do you skip meals?  Yes  No
If yes,  Breakfast  Lunch  Dinner Reason for skipping: _______________________
Do you eat out?  Yes  No
Type of setting? Cafeteria style
Fast food
Buffet
Sit-down restaurant others
Weight loss program attempted in the past______________________________________________
________________________________________________________________________________
Are you currently trying to lose weight? Yes
No
What are you currently doing to promote weight loss?______________________________________
Your nutritional knowledge Good
Fair
Do you eat your meal at same time each day? 75-100%
Poor
50-75%
25-50%
0-25%
Type of beverages drink daily and how much?____________________________________________
Any food preparation issues?_________________________________________________________
Issues affecting food intake? none
Food cravings Emotional /stress eating
Vegetarian
Nausea/Vomiting Religious
Other_____________________________________________
Barrier to making changes, if any? _____________________________________________________
How active are you at home or work during the day?
 Not active
Somewhat Active
Very active
Changes made in eating/exercise/others since diagnosis, if any?_____________________________
________________________________________________________________________________
1/9/2013
DIRECTIONS TO BAYLOR MEDICAL PLAZA
DURING HWY. 114 CONSTRUCTION
From 114 North (Lewisville, Irving/DFW Airport)
Exit William D Tate
Stay on service road and exit Hwy 26 aka Ira E Woods. (toward Baylor G-vine hospital)
Go straight at light onto Baylor Parkway
Cross rail road tracks
At the 4 way stop take a right onto Lancaster Dr.
Follow Lancaster around the east side of hospital
Take a left at 3 way stop sign onto College St.
Right into Medco parking lot (orange brick building) just before the service road
Follow drive all the way into our parking lot
From 360 and 121 (Irving, Bedford)
Exit William D Tate
Stay on William D Tate (pass restaurants)
Cross bridge over 114
Take a left onto the service road
Follow service road and exit Hwy 26 aka Ira E Woods. (toward Baylor G-vine hospital)
Go straight at light onto Baylor Parkway
Cross rail road tracks
At the 4 way stop take a right onto Lancaster Dr.
Follow Lancaster around the side east of hospital
Take a left at 3 way stop sign onto College St.
Right into Medco parking lot (orange brick building) just before the service road
Follow drive all the way into our parking lot
From 114 South (Trophy Club)
Exit 1709 aka Southlake Blvd
Take a left over bridge
This puts you on Northwest Hwy
Follow about 2-3 stop lights
Take a right onto Dove Rd
When road splits stay right onto Wall St
Follow Wall St through 2-3 stop signs
After last stop signs and houses on left (just before you get to 114)
Turn left into our parking lot
We are the 3 story gray building
From 1709 (Southlake Blvd)
Go straight at light over 114 bridge
This will put you on Northwest Hwy
Go straight on Northwest Hwy
Take a right on Dove Rd., When road splits stay right onto Wall St.
Follow Wall St. through 2-3 stop signs
After last stop sign and houses on left (just before you get to 114)
Turn left into our parking lot
We are the 3 story gray building
Map and Directions
Diabetes Education Center
Northwest Hwy.
Park Blvd.
Wall St.
Southlake Blvd.
114
Diabetes
Education
Center
Baylor Medical
Plaza
14
y. 1
Hw
College St.
114
Grapevine
Southlake
a
t hl
lv
eB
d
2020 W. Hwy. 114, Suite 120, Grapevine, TX 76051
817.424.4542 • BaylorHealth.com/GrapevineDiabetes
N. M ain St
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Lancaster Dr.
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Baylo
377
Baylor Regional
Medical Center
at Grapevine
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oods A
Baylor Diagnostic
Ira E W
Imaging Center
Baylor Regional Medical
Center at Grapevine
Baylor Breast Center
26