Diabetes Wellness Questionnaire

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Name *

Date of Birth *

Month

Day

Year

Do you have a regular walking or exercise routine?

How many times a week do you exercise?

What kind of exercise routine?

On a scale of 1-10, with 10 being excellent, how would you rate your dietary adherence?

Would you like us to schedule a dietitian consultation for you?

What do you struggle with the most when it comes to your diet?

What is the name of your eye doctor?

Last Eye Appointment

Have you been prescribed a glucometer to check your blood sugar levels?

Do you check your blood sugar levels?

How often?

Average Reading of Recent Blood Sugar

Last A1C Level

Do you regularly check your blood pressure?

Recent Blood Pressure Reading

What is your blood pressure target?

Do you regularly check your foot health?

Have you had any chest pain or heart issues since your last visit?

Have you quit any medications since your last visit?

Have you run out of any medications since your last visit?

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