* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has diabetes mellitus, please answer the following:

1. Type of Diabetes?   Insulin      Non-insulin      Diet      Gestational  

            Date diagnosed?  

2. Type of medication and dosage?  

3. Has your client ever been hospitalized for diabetes?   Unknown Yes No

            When?         Duration? 

4. When was your client last seen by the Doctor?     

5. How often are the visits to their Doctor?  

6.     a. Does your client have glycohemoglobin or hemoglobinA1C test done? 

            Unknown Yes No   What are the results?  

        b. Does your client test his/her own sugar?   Unknown Yes No  

            What is the average?  

        c. Date of last blood glucose level?      Results?   

        d. Is the client and the doctor pleased with the results and control?   Unknown Yes No

7. Has your client had kidney problems?   Unknown Yes No

            If yes, please explain:  

8. Has you client had protein in urine?   Unknown Yes No  

           Please give details?  

9.Has your client had any problems with his/her eyes?   Unknown Yes No

            Please give details?  

10. Any high blood pressure?   Unknown Yes No  

            When and how much?     

11. Any "heart trouble"?  Unknown Yes No   

            If yes, please explain?  

12. Any neurological symptom, loss of feeling in feet?   Unknown Yes No

            If yes, please explain?     

13. Does your client have any other major health problems

     (example heart disease, etc)?    Unknown Yes No  

            If yes, please explain: