Sansum Diabetes Research Institute

Demographic Information:

Today's Date: ____ /_____ /____ Social Security: ______ -_____ -______

Name:_____________________________________ Date of Birth: ____/____/____

Address:____________________________________________________________

City:___________________________ State: ___________ ZIP:_______________

Phone:(W) ___________________________ (H)____________________________

Emergency Contact:________________________________(____)_____________

E-mail: ______________________________ Gender: Male Female

Ethnic Group: Caucasian African American Hispanic Asian Other:________________

Current Care Information:

Primary Care Physician:_______________________________(______)__________

Specialist Physician:__________________________________(______)__________

Social History:

Birthplace:____________________________

Occupation:___________________________

Marital Status:_________________________ Children:______________________

Form of exercise:_______________________ Frequency:____________________

Smoking: Yes No If yes, packs per day:_____________ Years:_________________

Alcohol use Yes No If yes, drinks per day:_____________ Years:_______________

Do you or have you used recreational drugs? ______________________________

Females Only:

Are you able to get pregnant: Yes No Date of last menstrual period____/____/____

If No, why: Surgically sterile date of surgery ____/____/____

Postmenopausal are you using hormone replacement therapy: Yes No

Use of birth control what do you use? ____________________________________

Start date of use ___/___/___

If Yes, are you planning to get pregnant: Yes No If yes, when? ________________

Medical Problem	Start Date	Stop Date	Treatment

Surgical History:

Operation	Reason	Date

Relevant Family History : (First degree relatives only)

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Allergies:

___________________________________________________________________

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History of Diabetes :

What year did you develop diabetes?_______________

Did you require pills at the time of diagnosis? Yes No

Do you use Insulin? Yes No If yes, start date of insulin use?___________________

Do you use an insulin pump: Yes No If yes, start date of use?_________________

Blood Glucose Control :

Do you monitor your blood sugar at home? Yes No If yes, how often? __________

What are your blood sugar results? ______________________________________

Diet Information :

What do you typically eat for:

Breakfast:_________________________________________ Time:_____________

Lunch: ____________________________________________ Time:____________

Dinner: ____________________________________________ Time:____________

Snack: ____________________________________________ Time:____________

Dessert:___________________________________________ Time:____________

Please indicate whether you have a history of any of the following conditions and the month and year of diagnosis:

Diabetic Retinopathy (Eye disease) No Yes ____/_____

Diabetic Neuropathy (numbness or tingling in hands/feet ) No Yes ____/_____

Cardiovascular Disease (Heart disease) No Yes ____/_____

Peripheral Vascular disease (Poor circulation) No Yes ____/_____

Diabetic Nephropathy (Kidney disease) No Yes ____/_____

Sexual Dysfunction No Yes ____/_____

Is there anything you feel the physician should know about your condition that has not been covered on this form?

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Medication	Dose	Frequency	Start date	End date	Indication