<p> PATIENT IDENTIFICATION Healthplex at 1268 Lee Blvd Richland, WA 99352 Phone: 942-2660 GESTATIONAL ASSESSMENT </p><p>______Last Name First Name M.I. Date of Birth Height: ______Current Weight: ______Pre-Pregnancy weight: ______*Race:  Caucasian  African American  Hispanic  Native American  Asian  Other : ______* Information requested by the American Diabetes Association for statistical purposes Language:  English  Other: ______Interpreter Needed?  Yes  No Highest Level of Education: ______Occupation: Title ______Employer ______Working hours ______Do you live alone?  Yes  No Primary support person ______Do you have any concerns for your safety in the home?  Yes  No If yes, explain ______Does anyone in your family have diabetes?  Yes  No Who? ______Have you had diabetes education in the past?  Yes  No When? ______Where? ______Educator? ______Do you have difficulty obtaining supplies or medications?  Yes  No If yes, is the difficulty related to:  Cost  Transportation  Other: ______HEALTH HISTORY Primary Physician: ______Other physicians/problems treated: ______Known Adverse & Allergic Reactions (identify type of reaction)</p><p>Known Significant Medical Diagnoses/Conditions Onset Onset Onset Onset Dx/Conditions Dx/Conditions Dx/Conditions Dx/Conditions Date Date Date Date Heart Disease Respiratory Cancer Back/neck pain Chest Pain Sleep Apnea Cataracts Infectious Disease Heart Attack Thyroid Glaucoma Implants/prosthesis Pacemaker Stroke GI/Liver Psych Hx/Depression Hypertension Seizures Kidney Metal in Body Rheumatic Neuro Other: Fever Pregnancy Due Date: No. Pregnancies: Medicine/Prenatal vitamins:</p><p>0 7 6 6 1 of 4 Date: 05/22/14 No. Children/Ages:</p><p>MEDICATIONS: (Prescriptions, including insulin, oral diabetes medications, inhalers and eye drops, over the counter drugs PATIENT IDENTIFICATION like aspirin and ibuprofen products) Taking No Medications Unable to obtain medication history. Reason ______</p><p>Name of Prescribed Medication Dose Frequency Last Dose/Comments</p><p>Over the Counter Medications Dose Frequency Last Dose/Comments</p><p>Vitamins, Minerals & Herbals Dose Frequency Last Dose/Comments</p><p>Known Significant Operative & Invasive Procedures/or Treatment History: Date Date</p><p>Date Date</p><p>Date Date</p><p>------Staff Use Only – Reviewed By: Print Name & Title ______Date of Entry ______Print Name & Title ______Date of Entry ______PERSONAL HISTORY Are you currently experiencing any of the following?  No  Yes (if answer is yes, continue below)  Constipation  Changes in appetite  Feeling of tiredness  Personality changes</p><p>#0766 2 of 4 Date: 05/22/14 Have you smoked or used tobacco in the last 12 months?  Yes  No If yes, how much per PATIENT IDENTIFICATION day? ______What kind?  Cigarettes  Cigars  Chewing tobacco  Other: ______Would you like information on quitting or help maintaining your smoke-free status?  Yes  No Do you drink alcohol?  Yes  No If yes, how much per day? ______Per week? ______Do you have frequent bladder infections?  Yes  No</p><p>DIABETES MEDICINES (if you are taking any) How many times a week do you:  Skip a dose or  Take it more than an hour later than planned? ______If you take insulin, where do you inject?  Abdomen  Arms  Leg  Other: ______Where do you keep the insulin you’re using now? ______Extra supply of insulin?______</p><p>MONITORING Do you check your blood sugar at home?  Yes  No  I don’t have a meter How often do you check your blood sugar? Times per day ______Times per week ______What meter do you use? ______Do you check your urine for ketones?  Yes  No  I don’t know what ketones are Do you ever have low blood sugar reactions?  Yes  No  I don’t know When? ______How many times per week? ______Per month? ______What do you eat or drink for low blood sugar?______Do you carry this with you?  Yes No</p><p>NUTRITION MANAGEMENT Do you follow any particular nutrition or meal plan?  Yes No If yes, what is it? ______Do you follow any of these food restrictions?  Low sodium Other: ______ Low fat  Low protein How many meals do you usually eat per day? ______Do you eat planned snacks?  Yes No How many times a week do you: Skip or  Delay a meal or snack? Meals ______Snacks ______How many times a week do you eat away from home? ______Where?______Do you ever binge (eat uncontrollably)?  Yes No If yes, how often? ______Who usually shops for food? ______Who usually prepares your food? ______Do you require financial assistance in purchasing food? ______</p><p>FOOD RECALL (Describe your typical eating habits) List all foods eaten a typical day and the approximate time you have each meal or snack. Include the specific amount and how it is prepared (fried, broiled, baked, etc.): #0766 3 of 4 Date: 05/22/14 Breakfast Tim Lunch Time: Dinner Time: e:</p><p>PATIENT IDENTIFICATION</p><p>Mid- Tim Mid- Time: Bedtim Time: morning e: afternoo e Snack Snack n Snack</p><p>EXERCISE Has your physician told you to avoid exercise while pregnant?  Yes  No How often do you exercise per week? ______What kind of exercise do you do? ______How long do you exercise each time? ______What time of day do you exercise? ______PAIN ASSESSMENT Do you have pain?  Yes  No Is the pain controlled?  Yes  No Rate pain level on a scale of 1 to 10 (with 10 as the worst): ______Location of pain ______When did it start? ______What causes pain? ______What relieves pain? ______EMOTIONAL ASPECTS OF DIABETES Diabetes affects the whole person and can give rise to feelings of anger, sadness or being overwhelmed. Have you been feeling sad or depressed?  Yes  No Are you getting less pleasure from your job, sports, or hobbies?  Yes  No Do you have trouble sleeping?  Yes  No Do you sleep too much?  Yes  No Do you often feel down on yourself, that everything is your fault?  Yes  No Do you have trouble making decisions or concentrating on your work?  Yes  No Circle any words that describe how you currently feel about your gestational diabetes: Overwhelmed Out of control Hassled Burdened Alone Angry What is you greatest fear about having gestational diabetes? ______Please list the three things that you most want to learn and/or change about your gestational diabetes and how you take care of it: 1. ______2. ______3. ______Patient’s Signature Date Educator’s Signature Date</p><p>#0766 4 of 4 Date: 05/22/14</p>