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You have invested in improving your diabetes management by purchasing an insulin pump. The pump alone will not ensure your success with the therapy. Your current diabetes self-management skills are important factors in this process. Please answer the below questions to the best of your ability so that we can better assist you in achieving your goals. Name: _______________________________________________________ Date of Birth:___/___/___ Year Diagnosed with diabetes:________ Diabetes Management Number of injections/day:__________ Amounts: Breakfast_______ Lunch_______ Dinner________ Bedtime______ Do you vary your insulin dose depending on your food intake and or activity levels? Y___ N____ How often do you check your blood sugar? _____________x per day. How do you treat your low blood sugars? ________________________________________________ What was your most recent A1c test? __________________ Month of test: ____________________ Do you carbohydrate count? Y___ N___ If yes, what is your carb ratio? __________________ When did you last see a Registered Dietitian? _________________ When did you last see a Diabetes Nurse? ____________________ Do you correct your blood sugar based on an insulin sensitivity factor? Y___ N___ If yes, what is your ISF ?______ Do you feel your low blood sugars? Y___ N____ If any, what are your symptoms?__________________ Have you had an episode of DKA in the past year? Y___ N___ Check which best applies: Always Often Sometimes Never Do you check your blood sugar after meals? ___ ___ ___ ___ Do you check your blood sugar before driving? ___ ___ ___ ___ Do you carry your diabetes supplies with you? ___ ___ ___ ___ Do you have two accurate BG meters in your home? ___ ___ ___ ___ Do you wear Medic Alert™ Identification jewellry? ___ ___ ___ ___ Do you rotate your injection sites? Y___ N____ Special Considerations Please check any of the following which relate to you Shift work _______ Food Allergy_______ Skin sensitivity_______ Injection Site scar tissue________ Vision problems ____ Slow digestion______ Numbness in hands_______ Memory Problems________ Fear of injection pain_____ Fear of hypoglycaemia____ Live alone______ Variable lifestyle________ Other______________________________________________________________________________ What are your expectations of pump therapy? _____________________________________________ ___________________________________________________________________________________ What are your expectations of your pump trainer?__________________________________________ ___________________________________________________________________________________ What are your responsibilities to meet your expectations? ___________________________________ ___________________________________________________________________________________ Thank You! |
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