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* Date of Birth:* MM slash DD slash YYYY 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?