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: Breakfst_______ 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? _________________

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 2 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!   Your Diabetes Team.