Diabetic Form

DIABETES ASSESSMENT QUESTIONNAIRE

Demographics information: Step 1 / 4

Patient Initials (Eg:Tarun Mathur - TM)

Email Address

Phone Number

Date of birth

Gender

Height (cms)

Weight (kg)

BMI

Blood Sugar Level ( mg/dl )

Are you already diabetic?

Yes.

No.

Already Diabetic from ( months/years )

Complications information: Step 2 / 4

1. Do you experience unusual thirst without any increased physical activity?

Yes, regularly

Yes, less often

No.

2. Do you feel hungry, despite having regular meals?

Yes, I feel unusual hunger

Yes, my hunger is due to exercise

No.

3. Do you find yourself more tired?

Yes, without any reason.

Yes, due to mental stress.

Yes, due to exercise.

No.

4. Are you going for urination frequently, especially at night?

Yes, more than 5 times.

Yes, more than 2 times.

No.

5. Is your weight consistent?

Yes.

No.

5 A. If not, Then?

Gaining weight for last months/years.

Losing weight for last months/years.

6. Do you observe blurred vision, sometimes?

Regularly.

Thrice in a week

Once a week .

Rarely.

7. Do you feel like piercing ‘pins and needles’ or burning sensation in your hands and feet?

Yes.

No.

7A. If, Yes, for how many months?

Four months or more.

Less than four months.

Recently .

8. Do you feel your cuts and wounds require extra time to heel?

Yes, after all due care

Yes, due to less care

Not aware.

No.

9. Do you experience red, swollen and tender gums?

Yes, very often

Yes, due to medical condition

Rarely.

Not aware.

Disease Related Variables: Step 3 / 4

1. Any of your parents are already diagnosed with diabetes?

Yes, both mother and father.

Yes, mother.

Yes, father.

No.

2. Any of your other blood relatives are already diagnosed with diabetes?

Yes, many.

Yes, very few.

Don’t Know.

No.

3. Have you ever diagnosed with high blood glucose?

Yes, during health check-up.

Yes, during illness.

Yes, during pregnancy.

Never.

4. Do you smoke/chew tobacco/chew betel-nuts?

Yes, regularly.

Sometimes.

No.

5. Have you diagnosed with high blood pressure and taking anti-hypertensive medicines?

Yes, but not taking medicine.

Yes, regularly taking medicine.

No.

6. Do you take any medicines for other diseases?

Yes for Cardiovascular Disease.

Yes for Kidney Disease.

Yes for Liver Disease.

No.

7. If you are already diabetic, how often do you monitor your blood sugar?

Not regularly.

Once in a month.

Once in fifteen days.

Once in a week.

Non-diabetic.

8. If you are already diabetic, how do you manage your diabetes?

Do nothing.

Use Insulin with Oral medicines.

Use Insulin OR Oral medicine.

Manage with exercise and diet.

Non-diabetic.

Physical and Social Activity: Step 4 / 4

1. What amount of time you spend on physical exercise/Yoga during a Week?

Not specific.

30 min. every alternate day.

20 min. Daily .

2. Do you find yourself losing temper over small things?

Always.

Usually.

Sometimes.

Never.

3. How you find yourself socially active?

Very less active.

Moderately active.

Very active.

4. Do you find your life stressful?

Always.

Usually.

Sometimes.

Never.

5. What option do you choose for fighting with Stress/depression?

Nothing.

Seek psychological counselling.

Use Medication.

Seek social support.

Food Habits: Step 5 / 5

1. Do you believe changing dietary habits may help control diabetes?

No.

Don’t know.

Yes.

2. How regular are your diet plans?

No plans.

3 divided diets.

More than 3 divided diets.

3. What is the frequency (Weekly) of following foods in your diet?

Street/Fast food

Non-veg/High fat Diet

Chocolate/cakes/sweets

Vegetables/fruits

4. Have you been told to follow any diet restrictions?

Yes.

No.

4A. If Yes, what are they?

Low Calorie.

Low Cholesterol.

Low Protein.

Low Salt/sodium.

None.

5. Do you have any digestion related problems, such as?

Indigestion.

Constipation.

Diarrhoea.

Gastritis.

Nil.