DIABETES CARE CENTER QUESTIONNAIRE

1 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?

2 O NO o YES Do you smoke now? o NO o YES How many per day? _____If you quit, when?_____At what age did you start? _____Do you drink alcoholic beverages? o NO o YES How much? _____Are you on a special diet? o NO o YES If yes, what kind of diet? _____Your weight now:_____One year ago: _____States and countries in which you have lived? _____When did you move to florida? _____Previous occupations: _____Have you ever had an EKG? o NO o YES If yes, date of last one: _____Have you ever had a chest x-ray?

3 O NO o YES If yes, date of last one: _____DEVICESDo You ..o NO o YES Hearing Aids ..o NO o YES IUD ..o NO o YESC ontact Lenses ..o NO o YES Dentures ..o NO o YES Others _____WOMENM enstrual History:Age at onset:_____ o Regular or o Irregular Last menstrual period: _____Date of last pap smear or pelvic exam: _____Have you ever had an mammography? o NO o YES If yes, date of last one: _____Pregnancy:How many times pregnant?_____ Full term:_____ Premature: _____Abortions: Spontaneous:_____ Therapeutic: _____Living children:_____ Birth defects: _____Any complications with pregnancy?

4 _____Date of last childbirth: _____Any other information you would like to list: _____Doctor s Initials:_____