DATA COLLECTION FORM , DEPARTMENT OF PHARMACY

PRACTICE
SHRI VISHNU COLLEGE OF PHARMACY
PATIENT NAME:
PHONE NUMBER:
HEIGHT:
IP/OP NO:

AGE:
WEIGHT:

BMI:

C/O:

O/E:

PAST MEDICAL HISTORY:

PAST MEDICATION HISTORY:

FAMILY HISTORY:
SURGICAL HISTORY:
SMOKING:
VITAL SIGNS:
PARAMETERS
BP(mmHg)
PR(BPM)
RR(CPM)
TEMP(F)
LABORATORY INVESTIGATIONS:

SEX:

ALCOHOL:

DIAGNOSIS:
DRUG CHART
DRUG NAME

DOSE

FREQUEN
CY

ROA

QUESTIONARRIE ON AWARENESS OF DIABETES

MELLITUS TYPE II
KNOWLEDGE ON DIABETES
1) ARE YOU AWARE OF DIABETES MELLITUS?
AWARE (

UNAWARE (

2) WHAT DO YOU THINK IT IS?

CURABLE (

UNCURABLE(

3) ARE YOU AWARE OF TYPES OF DIABETES?

AWARE (

UNAWARE (

4) WHAT DO YOU KNOW ABOUT TYPE I DIABETES?

5) WHAT DO YOU KNOW ABOUT TYPE II DIABETES?

6) DO YPU KNOW THE DIFFERENCE BETWEEN TYPE I AND TYPE II

DIABTES?
YES (
)
NO(
)
ETIOLOGY
7)ARE YOU AWARE OF RISK FACTORS THAT CONTRIBUTE TO DIABETES MELLITUS
OBESITY(
)
FAMILY HISTORY(
)
HYPERTENSION( ) LACK OF

PHYSICAL ACTIVITY(
)SMOKING(
SIGNS OF INSULIN RESISTANCE (
)

) PCOS(

GDM(

) DYSLIPIDEMIA(

CLINICAL MANIFESTATIOS
8) DO YOU KNOW SYMPTOMS OF HYPERGLYCEMIA?
POLYURIA(
FEET(
)

) POLYDYPSIA(

NUMBNESS OF HANDS(

POLYPHAGIA(

) NOCTURIA(

) ABNORMAL SENSATION IN

) WEIGHT LOSS(

DIAGNOSTIC TESTS
9) DO YOU HAVE KNOWLEDGE OF DIAGNOSTIC TESTS THAT ARE DONE FOR
DIABETES MELLITUS?
10) OF THESE ANY ONE IS ENOUGH OR DO YOU NEED ALL TO CONFIRM?
FBG(
NONE( )

PPBG(

RBS(

HbA1C (

ALL(

12) IS IT IMPORTANT TO DO BOTH FASTING AS WELL AS POST PRANDIAL BLOOD

SUGAR LEVEL FOR DIAGNOSIS AND MONITORING?
YES (

NO(

13) APART FROM BLOOD SUGAR LEVEL ARE YOU AWARE ABOUT HbA1C ? YES (
NO(
)

14) DO YOU KNOW THE TARGET VALUES OF TESTS USED TO DIAGNOSE DIABETES
MELLITUS?
YES (

NO(

15) IF YES
FBS 80-130 MG/DL
PPBS 80-180MG/DL
HbA1C 7
NONE
16)ARE YOU SUPPOSE TO TAKE MEDICATIONS ON THE TEST DAY ? YES( )
)

DIABETIC COMPLICATIONS

NO(

17) DO YOU HAVE ANY IDEA ABOUT DIABETIC RELTED COMORBIDITIES? YES ( )
NO(
)
18) DO YOU KNOW PERSISTENT HYPERGLYCEMIA CAN AFFECT YOUR
EYES (
) HEART (
VESSELS(
)

) KIDNEYS(

) NERVOUS SYSTEM (

BLOOD

MANAGEMENT
19) ARE YOU TAKING MEDICATIONS REGULARLY?

YES (

NO (

ABOUT INSULIN
20) DO YOU KNOW THAT INSULIN IS ESSENTIAL FOR LIFE? YES (

) NO(

21) DO YOU KNOW ADMINISTRATION TECHNIQUE OF INSULIN?

NO (
)

YES (

22) DO YOU KNOW PROPER BODY SITES FOR INSULIN INJECTION?

NO (
)

YES (

)
)
)

23) ARE YO AWARE OF COMPLICATIONS THAT COULD OCCUR WHILE ON INSULIN?

AWARE(

UNAWARE(

24)DO YOU KNOW WHAT IS HYPOGLYCEMIA? YES (

NO(

25) HOW DO YOU RECOGNISE HYPOGLYCEMIA? SYMPTOMS(

)

)
)

LAB VALUES(

26) ARE YOU AWARE OF PRCAUTIONARY MEASURES TO TAKE IF HYPOGLYCEMIA

OCCURS?
YES(

NO(

27) DO YOU KNOW HOW TO ADJUST DOSE OF INSULIN WHEN YOU HAVE
HYPOGLYCEMIC EPISODE?
YES (

NO(

NON PHARMACOLOGICAL THERAPY

SELF CARE PRACTICES
28) ARE YOU AWARE OF SELF MONITORING OF BLOOD GLUCOSE IN DIABETES?
YES(
)
NO ( )
29) DO YOU KNOW WHAT ARE THE PREFERRABLE FINGERS TO PRICK AND CHECK
GLUCOSE LEVELS BY GLUCOMETER?
YES (

NO(

30) DO YOU FOLLOW FOOT CARE RECOMMENDATIONS ? YES (

)

NO(

LIFE STYLE MODIFICATIONS

31)DO YOU KNOW THE ADVANTAGE OF DAILY EXERCISES IN DIABETIC PATIENT?
YES(

NO(

32)ARE YOU PERFORMING PHYSICAL ACTIVITY DAILY ?

)

YES(

NO(

33) DO YOU KNOW HOW MUCH TIME THE PHYSICAL ACTIVITY HAS TO BE DONE
IN A DAY?
YES(

NO(

34)DO YOU KNOW HOW MANY TIMES THE AEROBIC EXERCISE HAS TO BE DONE
AWEEK?
YES(

NO(

35)DO YOU HAVE A MEAL PLAN ?

YES(

NO(

36 )IF YES HOW MANY CALORIES DO YOU TAKE DAILY ?

37) WHAT FOOD PLANNING METHODS DO YOU USE
a) NONE
COUNTING (

(
)

b) CARBOHYDRATE COUNTING

38)HAVE YOU BEEN TOLD TO FOLLOW ANY DIET RESTRICTION ?

NO(
)
39)IF YES a) LOW CALORIE (
c)LOW PROTEIN
d)HIGH FIBRE (

b)LOW CHOLSTROL(

e) HIGH FAT (

c) CALORIE
YES(

c)LOW SALT (

)
)