Transcription of DIABETES CARE CENTER QUESTIONNAIRE
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DIABETES CARE CENTER QUESTIONNAIRE
DIABETES care CENTERQUESTIONNAIREName: _____Date: _____Date of last physical exam:Is this a routine check-up? o YES o NO If no, list all symptoms you have _____2. _____3. _____4. _____RELATIVESF atherCancer: What kind?MotherTuberculosis:BrotherDiabetes: SisterHeart trouble:Insanity:SpouseHigh Blood Pressure:Suicide:SonStroke:Thyroid Disease:DaughterEpilepsy:AGEIF LIVING,HEALTH CONDITIONIF DECEASED,AGE OF DEATHCAUSEHAS ANY BLOOD RELATIVE EVER HAD:PLEASE CONTINUE TO THE NEXT PAGEPage 1 WHO:Patient Name: _____SOCIAL HISTORYHave you ever smoked?
Patient Name: _____ SOCIAL HISTORY Have you ever smoked? oNO YES Do you smoke now?NO YES How many per day? _____ …
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