Diabetes Interview

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DIABETES QUESTIONNAIRE

Name: _Martin Luther Date of Birth; _21/11/99

PID#; _-5.955

Campus/Local Address: _Yale University University od; _________

Phone; _+8143008226 Email; luthor566@yahoo.com

1. When were you first diagnosed with diabetes? Year; ___1999__Age; __25__

2. Please list all medication(s) you take, including dosage:

Miglitol (Glyset), Metformin Hydrochloride ER

Avandia

Glucvance

SKIP TO QUESTION 4 IF YOU DO NOT TAKE INSULIN.

If you use an insulin pump, please fill out the insulin pump section instead.

Time of Injection Units and Type of Insulin Units and Type of Insulin

______________ ______________

3. Where do you give your injection? ________________________________

Do you rotate sites with each injection? ___Yes ___No

Any problems with sites (lumping, pitting, etc.)? _________________________

4. Do you exercise regularly? Yes About how many times a week? __4___

Types of exercise; Skipping a rope, morning run

Usual time of day and length of time: 5am-7am

Problems with exercise-related low blood sugar reactions? yes

5. Any complications of diabetes? kidney damage

DIABETES QUESTIONNAIRE

Page2

Name; Martin Luther

6. Do you smoke? occasionally

If you stopped smoking how long ago did you stop? ______

How many cigarettes per day do/did you smoke? 4 For how many years? 7

Are you considering stopping? yes

7. If you consume alcohol, how much and how often?

If you drink alcohol, what adjustments do you make in your diet or insulin dose?

8. Do you check your blood sugar? Yes, Type of meter; AUVON DS -W Sugar kit

How often? 5 times a day

9. Do you check your urine for Ketones? Yes

When? _Once every year

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DIABETES QUESTIONNAIRE Name: _Martin Luther Date of Birth; _21/11/99 PID#; _-5.955 Campus/Local Address: _Yale University University od; _________ Phone; _+8143008226 Email; luthor566@yahoo.com 1. When were you first diagnosed with diabetes? Year; ___1999__Age; __25__ 2. Please list all medication(s) you take, including dosage: Miglitol (Glyset), Metformin Hydrochloride ER Avandia Glucvance SKIP TO QUESTION 4 IF YOU DO NOT TAKE INSULIN. If you use an insulin pump, please fill out the insulin pump section instead. 3. Time of Injection Units and Type of Insulin ______________ ______________ ______________ ______________ Units and Type of Insulin Where do you give your injection? ________________________________ Do you rotate sites with each injection? ___Yes ___No Any problems with sites (lumping, pitting, etc.)? _________________________ 4. Do you exercise regularly? Yes About how many times a week? __4___ Types of exercise; Skipping a rope, morning run Usual time of day and length of time: 5am-7am Problems with exercise-related low blood sugar reactions? yes 5. Any complications of diabetes? kidney damage DIABETES QUESTIONNAIRE Page2 Name; Martin Luther ...
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