GATEWAYCOMMUNITYHEALTHCENTER,INC.

DiabetesPatientAssessment
Name:______________________________________MasterFile#________________
Address:______________________________D.O.B.:______/______/______Date:_______
Smoking
Doyousmoke?
YES NO
HaveyouseenaDentistsinceyour
lastvisittotheFamilyPractice YES NO
Center/OutpatientClinic?
Hasitbeenmorethanoneyear YES NO
sinceyouhaveseenadentist?
Ifyouknow,pleaseenterthe
approximatedateofyourlast Date:_________
dentalvisit.
EyeExams
Haveyouvisitedaneyedoctor
sinceyourlastvisittotheFamily YES NO
PracticeCenter/OutpatientClinic?
Hasitbeenmorethanoneyear YES NO
sinceyouhaveseenaneyedoctor?
Ifyouknow,pleaseenterthe
approximatedateofyourlastvisit Date:_________
toaneyedoctor.
SelfManagement
Doyouexerciseregularly? YES NO
Haveyoubeenfollowingyour YES NO
diabeticdiet?
Haveyoubeentakingyour YES NO
medications?
YourComments:
**Pleasegivethisformtothenursewhenyouarecalledtotheexamroom**
Patient'sSignature:_____________________________Interviewer:__________________
DentalVisits
This product was developed by the diabetes self management project at Gateway Community Health Center, Inc. in Laredo, TX with supoort from the
Robert Wood J ohnson Foundationin Princeton, NJ .