Diabetes Clinic:
Pump Therapy Preparation Assessment Form

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________


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!
- Your Diabetes Team.