Diabetes Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Sex:MaleFmaleWhat are the problems that bring you to this office? Are you currently (check one only)MarriedSingleSeparatedWidowedDivorcedSeparatedPlease indicate which chronic condition(s) you haveType 1 diabetesType2 diabetesHigh CholesterolHypertensionHeart diseaseLung diseaseOthers specifyIn general how would you rate your healthExcellentVery goodGoodFairPoorWere you discouraged by your health issue?NoneA littleSome whatA good bitMost ofAll the timeWere you fearful about your future health?NoneA littleSome whatA good bitMost ofAll the timeWas your health a worry in your life?NoneA littleSome whatA good bitMost ofAll the timeWere you frustrated by your health problem?NoneA littleSome whatA good bitMost ofAll the timeWere you tied energy wise or fatigued? NoneA littleSome whatA good bitMost ofAll the timeWere you having pain in your legs or feet?NoneA littleSome whatA good bitMost ofAll the timeWere you having shortness of breath?NoneA littleSome whatA good bitMost ofAll the time In the PAST WEEK, did you have any of the following symptoms? Increased thirstDry mouthDecreased appetiteNausea or vomitingAbdominal painFrequent urinationNightmaresNight sweatsLightheadednessShakiness or weaknessIntense hungerFainted, passed out or lost consciousnessHas your health interfered with your normal social activities with family friends or neighbors or groups? Not at allSlightlyModeratelyQuite a bitAlmost Always Has your health interfered with your hobbies or recreational activities?Not at allSlightlyModeratelyQuite a bitAlmost AlwaysHas your health interfered with your household chores? Not at allSlightlyModeratelyQuite a bitAlmost AlwaysHas your health interfered with your errand and shopping? Not at allSlightlyModeratelyQuite a bitAlmost AlwaysDo you have a machine to measure your blood glucose level? YesNo How many days in last week did you check your blood glucose levelOn day you checked your blood glucose, how many times do you test on averageStretching or strengthening exercisesNoneLess than 30min30-60mins1-3 hoursMore than 3 hr/wkWalk or exercisesNoneLess than 30min30-60mins1-3 hoursMore than 3 hr/wkSwimming or aquatic exerciseNoneLess than 30min30-60mins1-3 hoursMore than 3 hr/wkBicycling including stationaryNoneLess than 30min30-60mins1-3 hoursMore than 3 hr/wkAerobic (stair master, rowing etc.)NoneLess than 30min30-60mins1-3 hoursMore than 3 hr/wkHow confident do you feel that you can eat your meals every 4-5 hours everyday including breakfast. Not at all ConfidentVery ConfidentHow confident do you feel when eat your meals with others who are not diabetics?Not at all ConfidentVery ConfidentHow confident do you feel that you can choose appropriate foods when hungry (for example snacks etc.)?Not at all ConfidentVery ConfidentHow confident do you feel that you can exercise 15 to 30 minutes, 4-5 times a week?Not at all ConfidentVery Confident How confident do you feel that you can do something to prevent your blood sugar level dropping when you exercise?Not at all ConfidentVery ConfidentHow confident do you feel that you can do something to lower your blood sugar level when it goes higher or lower than it should be?Not at all ConfidentVery ConfidentHow confident do you feel that you can do something to prevent your blood sugar level dropping when you exercise?Not at all ConfidentVery ConfidentHow confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do?Not at all ConfidentVery ConfidentHow many times last week did you eat breakfast when you wake up? This morning did you eat any of the following food for breakfast? Milk ½ cupCheeseYogurtEggsMeat or poultryBeansDid you take pills for diabetes past week?YesNoDon’t knowPlease specify the names of pills you tookIn the past week did you get any insulin injections?YesNoDon’t knowPlease specify the name of blood pressure pills you tookIn the past week did you took any cholesterol pill?YesNoDon’t knowPlease specify the name of cholesterol pills you tookPrepare a list of questions to askNeverAlmost NeverSometimesFairly oftenVery oftenAlwaysAsk questions about the things you want to know about your treatmentNeverAlmost NeverSometimesFairly oftenVery oftenAlways Discuss any personal problem that many relate to your illnessNeverAlmost NeverSometimesFairly oftenVery oftenAlwaysIn past six months how many times did you visit a doctor?In past six months how many times did you visit an emergency department in a hospital? In past six months how many total Nights you spent in a hospital?When was last time you had your eyes examined? (for glaucoma or any other problems) How many time doctor or nurse examined your feet in past six months?WebsiteSubmit