Diabetes History Form
1. Education Major
2. Marital Status
3. How many people live in your household?
4. Is there anyone who will help you in your diabetes care?
No If yes, who
5. Do you work outside of taking classes?
6. Diabetes provider at home
1. How long have you had diabetes?
2. List any family members with diabetes
3. How would you rate your understanding of diabetes?
4. What areas of diabetes would you like to learn more about?
Low blood sugar
Pills for diabetes
High blood sugar
Pregnancy and diabetes
5. How do you learn best?
6. What is your goal for this session?
Learn more about diabetes
Help with meal planning
Better blood sugar control
1. Has your weight changed in the last 3 months?
Was this weight change intentional?
2. How many times do you eat per day?
3. How often do you eat/drink the following? (per week)
Milk (fat free,
1%, 2%, whole)
4. How often per week do you eat away from home?
5. How is your food prepared?
6. How would you describe your portions?
7. Any special diet needs or practices?
8. Have you ever been told you have
High blood pressure
9. What diet plan do you typically follow?