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FOR DIABETIC

Diabetes Reversing Assessment Form

The following questions, which should be asked and answered during an interactive session with the patient, are designed to enable health care providers to identify patients with diabetes who, despite therapy, are not achieving their goals. Review of the patient’s responses should help clarify barriers to controlling glucose levels and optimal management of diabetes.

Name

Email

Age

Country

Contact No.

Whatsapp No.

Gender

Fasting Blood Glucose (date/result_)_:

1. Have you ever been told by a health care provider that youhave diabetes?

Yes (If yes, skip to question 3) No

2. Have you ever been told by a health care provider that your blood sugar is too high (fasting blood sugar 100-125 mg/dL) and you could get diabetes?

Yes (If yes, skip to question 3) No

(If the patient has high blood sugar but not yet diabetes, do not proceed with the questionnaire and refer to ADA Standards of Medical Care in Diabetes–2017 on the screening and criteria for diagnosis of diabetes.)

3. Are you taking oral medications to treat your diabetes?

Yes (If yes, skip to question 3) No

a. How many oral medications are you taking to treat your diabetes?

b. Name(s) of medication(s) and dosage(s):

c. When and how often do you take your oral medications?

4. Are you currently taking Hormones to control your diabetes?

Yes No

a. Name(s) of medication(s) and dosage(s):

b. When and how often do you take your Hormones medications?

5.Do you regularly measure your blood sugar level and record results?

Yes No (If no, skip to question 7)

6.How many times a day do you measure your blood sugar level?

1–2 3–4 5+

7.Do you have your A1C tested at least twice a year?

Yes No Don’t know what A1C is

(Patients should have their A1C tested quarterly if they are not meeting their target glycemic goals or their therapy has changed.)

8.Are you following a meal plan?

Yes No

a. Do you count carbohydrates?

Yes No

Patient DOB:

Most Recent A1C, if available (date/result):

9. Has your weight changed in the last 6-12 months?

Yes No

a. If yes, did you gain or lose weight and how many pounds?

10.Are you physically active at least 150 min/week with moderate-intensity aerobic physical activity?

Yes No

11.Have you been in the emergency room or hospitalized for a condition related to your diabetes in the last 12 months (date/results)?

Yes No

12.Have you had a thorough foot examination in the last 12 months (date/results)?

Yes No

13.Have you had your eyes checked by a specialist in the last 12 months (date/results)?

Yes No

14.Have you had your lipids/cholesterol checked in the last 12 months (date/results)?

Yes No

15.Have you had a microalbuminuria test/urine test for protein in the last 12 months (date/results)?

Yes No

16.Do you have high blood pressure?

Yes No

a.If yes, do you take medication to control your blood pressure?

Yes No

b. Name(s) of medication(s) and dosage(s)?

17.Are you a current smoker?

Yes No

18.Do you have a family history of heart disease?

Yes No

19.Do you take medication(s) for a condition/illness other than diabetes?

Yes No

a. Name(s) of medication(s) and dosage(s):

Provider’s Notes:
Patient’s overall effectiveness at controlling his/her diabetes:

Excellent Good Fair Poor

If patient is not controlling his/her diabetes, list possible steps that can be taken to improve control:

Patient’s risk for ASCVD

High Medium Low

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