New Patient Diabetes Questionnaire Web "*" indicates required fields New Patient Diabetes QuestionnaireIF YOU HAVE DIABETES, please review and complete the diabetes questionnaire below. This questionnaire will allow us to have a better understanding of what we need to do to help you become successful with controlling your diabetes. Thank you for your honest input.Full Name* At what age was your diabetes diagnosed? Have you seen a diabetes educator? Yes No Have you seen a nutritionist regarding your diabetes? Yes No What type of diabetes do you have? Type 1 Type 2 Diabetes in pregnancy Do not know Do you check your blood sugars at home? Yes No If yes, what is a high reading for you? what is a low reading for you? Do your sugars ever go below 70? Yes No If yes, is this daily weekly monthly rarely Are you aware of when your sugars go low? Yes No Have you been hospitalized for low blood sugars? Yes No If yes, when and where Do you know what an A1c is? Yes No If yes what is it? If yes, when and where Do you have diabetes related eye problems? Yes No Eye Doctor: When was your last eye exam? Never Never Do you have foot problems? Yes No Who is your Foot Doctor: When did you last give a urine sample for your diabetes? Never Never Do you have diabetes related kidney problems? Yes No When did you last have a cardiac assessment? Never Never Do you have heart disease? Yes No Males: Do you have erectile dysfunction? Yes No Do you have any specific issues you would like to address with your physician regarding your diabetes?