Microsoft word - 31405df0.docx

Marital Status:  Single Married Divorced Widowed Separated Source of referral: Self referred  Physician/Provider Other Referring/Primary Care Provider and telephone number:  White  American Indian/Alaska Native  Asian  Native Hawaiian/Pacific Islander  Spanish/Latino/Hispanic  Please describe your reason(s) for Meeting with the Dietitian today: ________________________________________________________________________ ________________________________________________________________________ Do you have any of the following nutrition related concerns? Please list food intolerances or food allergies: ____________________________________________________________________ Have you previously attempted any diets to assist with the following problems? blood glucose management (diabetes, prediabetes)  weight loss (please continue to next page) If yes, please describe: _________________________________________________ Diet for other reason not previously mentioned: _____________________________ Have you at any time in the past met with another registered dietitian, or licensed nutritionist?  Yes (when?) ________  No Whose nutritional guidance do you value now, or have you valued in the past? ________________________________________________________________________ Do you follow any particular eating regimen/nutrition plan currently (please name or describe): What are your goals with this plan? _________________________ Have you attempted any of the following diets for weight loss?: (please mark all that apply and briefly describe) Medical and Health Care Treatments for Weight Loss Have you ever been advised by a doctor to limit your exercise in any way? Has your weight changed in the past year?  Yes No How much? Do you use or have you used tobacco products?  No  Yes When did you quit? What hobbies bring enjoyment to your life? Please list all of your medications, prescription and OTC Do you have any drug allergies or intolerances? What type of reactions did you experience? What are your health care goals and how can we facilitate those goals? Have you previously had any diabetes education? Yes (when where?) If yes, did you find this helpful? Yes No Do you current check your own blood sugars with a home glucose meter? ?Yes ?No If yes: Do you know the name of your meter? _______________________ How old is the meter you current use? ________________________ Do you like your current meter? ?Yes ?No How often do you current check your blood sugars? ______________ Do you keep a record of your blood sugars? ?Yes ?No Did you bring you glucose meter with you today? ?Yes ?No Do you know your blood sugar number goals? ?Yes ?No Fasting goals: _______ 2 hours after meal goals:_______________ Are there any topics below you would like to discuss specifically today? Please mark all that apply Nutritional Guidelines Medicines (by mouth, or via injection) Blood Sugar Monitoring Goals A1c test Cholesterol test goals Exercise Guidelines Foot Care Complications associated with Diabetes Other Concerns regarding diabetes Stress management  Other ______________________________

Source: http://diabetesalaska.com/Assets/NutritionIntakeForm.pdf