Diabetes Assessment Form Step 1 of 2 50% First Name*Last Name*Email* Date MM slash DD slash YYYY Have you had a Microalbumin test done in the last 12 months? Yes No Microalbumin Test Date MM slash DD slash YYYY Microalbumin Test ResultHave you had a full foot exam by your doctor done in the last 12 months? Yes No Full Foot Exam Date MM slash DD slash YYYY Full Foot Exam Results Normal Abnormal Do you inspect your feet every day? Yes No Have you had a HgbA1c drawn at least once every 6 months over the last 12 months? Yes No HgbA1c Date MM slash DD slash YYYY HgbA1c Result Have you had a Fasting Lipid profile drawn at least once over the last 12 months? Yes No Lipid Profile Date MM slash DD slash YYYY Total CholesterolLDLHDLTriglyceridesDo you check your blood sugar daily? Yes No Do not own a glucometer What was your most recent blood sugar reading?Have you had a dilated eye exam by an Ophthalmologist in the last 12 months? Yes No Dilated Eye Exam Date MM slash DD slash YYYY Result Normal Abnormal Have you ever been told that your diabetes has affected your eyes? Yes No Do you take a daily aspirin? Yes No no MD order Have you had any changes in your Diabetes medications? Yes No If yes, please list changesHave you achieved your current Diabetes goal? Yes No What goal do you want to achieve for your Diabetes before your next follow-up?** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness!EmailThis field is for validation purposes and should be left unchanged. Δ
