Questionaire Form | Diabetes Connection

Please fill out the requested information below as best as you can.

This is a multi-page form.

This form will be sent directly to Coaching for Diabetes once you click the submit button. This is a confidential form and will not be shared with anyone outside of our sessions.

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General Information

First Name(Required)

Last Name(Required)

Today's Date

Date of Birth

Preferred Pronoun

Preferred Phone Number(Required)

Preferred Email(Required)

Do you prefer video calls OR phone calls for visits?

Video Calls

Phone Calls

Who manages your diabetes?

Primary Care

Endocrinologist

Primary Care Physican Name

Endocrinologist Name

Medical History

Please tell us if you have any of the following medical issues. You can check multiple medical issues on this form.

Do you have any of the following?

Asthma/Bronchitis/COPD

Stomach Problems

Heart Problems

Arthritis

Thyroid Disorder

Do you have any of the following? Column 2

Sexual Problems

Low Blood Sugars

High Blood Sugars

Acid Reflux/GERD

High Blood Pressure

Do you have any of the following? Column 3

High Cholesterol

Cancer

Liver Disease

Sleep Apnea

Anxiety/Depression

Do you have any of the following? Column 4

HIV/AIDS

Type of Eating Disorder

Other

If you selected Other from above, please explain.

Allergies?

Do You Smoke?

Yes

What do you smoke?

How Many?

How Long?

Previous History?

Is remembering to take your medication a challenge for you?

Yes

How Often?

Medications

Please tell us what medications you are currently taking.

Medicine Name | Dose? | How Often? | What Time?

Medicine Name

Medication Dose - How Much?

How Often?

What Time?

For multiple medicines, click on the + icon on the right of the form to add more.

Diabetes History

Please tell us your diabetes history.

What type of diabetes do you have?

Type 1

Type 2

Pre Diabetes

Gestational

I don't know?

How long have you had diabetes?

Does anyone in your family have diabetes?

Yes

Who in your family has/had diabetes?

Mother

Father

Brother/Sister

Grandfather

Grandmother

Other

If you selected Other from above, please explain.

Diabetes History Part B

Have you attended a diabetes education class before?

Yes

What year?

Do you check your blood sugars?

Yes

When do you check your blood sugars?

Breakfast

2 hours after meals

Before Bedtime

Before Meals

Other

Results Before Meal

Results After Meal

Results Before Bedtime

Do you keep a record?

Yes

Meter

Yes

CGM

Yes

How often have you had low blood sugar in the last 3 months?

How often have you had high blood sugar in the last 3 months?

What time of day did you have low blood sugar in the last 3 months?

Morning

Afternoon

Evening

What time of day did you have high blood sugar in the last 3 months?

Morning

Afternoon

Evening

Do you feel symptoms when having low blood sugar?

Yes

Symptoms?

Treatment?

Do you wear a medical ID?

Yes

Do you test for ketones?

Yes

When do you test for ketones?

Diabetes History Part C

Do you have any Eye Problems?

Yes

Do you have any Kidney Problems?

Yes

Do you have any Numbness/Tingling/Loss of Feeling in Feet?

Yes

Do you have Heart Disease?

Yes

Do you have Circulation Issues in your Feet/Legs

Yes

Do you have an annual eye exam?

Yes

Date of Your Last Eye Exam?

Do you go to the dentist 2x a year for cleaning?

Yes

N/A

Do you see a podiatrist?

Yes

How often do you see a podiatrist?

Once a year

Every 2-3 months

Do you enjoy movement/exercise?

Yes

Any specific form of movement you perform?

How many days per week?

Is there anything that interferes with your ability to move?

Yes

Please describe what interferes with your ability to move.

Meals

Do you follow a specific meal plan?

Yes

Please describe your meal plan:

Do you skip meals?

Yes

Which meals do you skip meals?

Breakfast

Lunch

Dinner

Have you been on multiple diets throughout your life?

Yes

Does your eating ever feel out of control?

Yes

Is there anything about your eating you'd like to change?

Yes

Please describe what you would change in regards to your eating.

Your Body

Approximately how many hours do you sleep at night?

Select your answer from the drop-down menu.

Do you have difficulty falling asleep at night?

Yes

Please check how you would describe your current body image?

Hatred

Negative

Neutral

Positive

Very Satisfied

How do you feel about diabetes?

(Mark all that apply)

Acceptance

Adaptation

Anger

Denial

Fear

Guilt

Overwhelmed/Confused

Sadness/Depression

How would you rate your stress level?

High

Medium

Low

Do you feel you have support and connection in your life?

Yes

Who supports and connects in your life?

(Mark all that apply)

Family

Friends

Co-workers

Faith

Doctor/Provider

Therapist

Other

If you selected Other from above, please explain.

Do you use anything to help improve your mood?

Yes

What do you use to improve your mood?

(Mark all that apply)

Marijuana

Alcohol

Food

Exercise

Meditation

Yoga

Music

Conection with others

Other

If you selected Other from above, please explain.

What is the most difficult thing about having diabetes?

Have you ever felt diabetes/weight shame or stigma from others?

Yes

From who?

(Mark all that apply)

Spouse

Family

Coworkers

Friends

My Doctor/Provider

Other

If you selected Other from above, please explain.

What would you need to happen/change in order for you to feel our time together was successful?