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New Patients Only: Referral Info
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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Want access to online portal?
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If yes.....Preferred Email Address
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Anything special we need to know
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PIR New Patient Quesstionairres
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PIR New Patient Questionnaires
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Blood Sugar's Assessment Questions
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Encounter
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Type
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BLOOD SUGARS
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1. How many times are you checking your blood sugars a day?
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Click Here to answer question's 2 & 3 unless your answer to question 1 was "none"
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2. What are your blood sugar readings?
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Fasting Blood Sugar (FBS)
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Before Meals
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Midmorning
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After Meals
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Midafternoon
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Before Bed
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3. Did you have any blood sugars less than 80mg/dL since your last treatment?
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DIET
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1. Are you counting carbohydrates (sugars)?
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2. How many carbohydrates are you consuming per meal?
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3. How many meals are you eating a day?
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4. Do you portion control your meals?
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5. Do you snack during the day?
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6. Do you snack before bedtime?
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7. What do your snacks consist of?
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EXERCISE
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1. Do you exercise?
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2. What exercise do you do?
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2. Answer only if "other" was selected
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3. How often do you exercise per week?
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4. How many minutes do you exercise at a time?
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ENERGY
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1. Has your energy level changed since last treatment? Or Recently for New patients.
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2. What is your energy level today? 1= No Energy, 10= Lots of energy
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3. What was your energy level last treatment? 1= No Energy, 10= Lots of energy
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SLEEP
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1. How many hours of sleep are you getting a night?
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2. How many times a night are you getting up to void?
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WOUNDS
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1. Do you have any open wounds?
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If Yes......Click here & fill out questions 2 & 3
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2. Where are the wounds?
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2. Answer only if "other" was selected
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3. How old are the wounds?
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NEUROPATHY
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1. Do you have any numbness and tingling in your hands?
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2. Do you have any numbness and tingling in your feet?
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3. Describe the sensation in your hands.
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4. Describe the sensation in your feet.
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5. Any change in your neuropathy since last treatment?
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RETINOPATHY
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1. Have you been diagnosed with retinopathy?
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2. Have you had an eye exam since your last treatment?
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3. Any visual changes since your last treatment?
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If yes to visual changes.....What changes?
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4. Do you receive injections for retinopathy?
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5. How often do you receive injections?
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NEPHROPATHY
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1. Do you have kidney problems?
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2. Are you on dialysis?
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3. Are you on a fluid restriction?
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If yes to Fluid Restriction......What is your fluid restriction?
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ERECTILE DYSFUNCTION (Males Only)
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1. Do you have erectile dysfunction?
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2. Has there been any improvement since last treatment?
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Michigan Neuropathy Screening Instrument
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Encounter
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Type
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A. History (To be completed by the person with diabetes)
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Please take a few minutes to answer the following questions about the feeling in your legs and feet.
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Check yes or no based on how you usually feel. Thank you.
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1. Are your legs and/or feet numb?
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2. Do you ever have any burning pain in your legs and/or feet?
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3. Are your feet too sensitive to touch?
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4. Do you get muscle cramps in your legs and/or feet?
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5. Do you ever have any prickling feelings in your legs or feet?
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6. Does it hurt when the bed covers touch your skin?
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7. When you get into the tub/shower, are you able to tell the hot water from the cold water?
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8. Have you ever had an open sore on your foot?
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9. Has your doctor ever told you that you have diabetic neuropathy?
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10. Do you feel weak all over most of the time?
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11. Are your symptoms worse at night?
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12. Do your legs hurt when you walk?
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13. Are you able to sense your feet when you walk?
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14. Is the skin on your feet so dry that it cracks open?
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15. Have you ever had an amputation?
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EQ-5D-5 Level
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EQ-5D-5 LEVEL
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Encounter
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Type
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Mobility: Problems Walking?
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Self Care: Washing and Dressing Myself?
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Usual Activities: Functioning in Day to Day Life (e.g. work, homework, family, leisure activities)
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Pain/Discomfort
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Anxiety/Depression
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We would like to know how good or bad your health is TODAY. Pick a # between 0-100. 0 = WORST Health. 100 = BEST health
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Vision Questionnaire VF-14. QOL
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VF-14 QOL Questionnaire
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Vision difficulties: Rate how difficult these activities are for you.
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Check the box that best describes how much difficulty you have, even with glasses.
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1. Reading small print: such as medicine bottle labels, a telephone book, or food labels
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2. Reading a newspaper or book.
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3. Reading a large print book or newspaper or numbers on a telephone
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4. Recognizing people when they are close to you.
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5. Seeing steps, stairs, or curbs
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6. Reading traffic signs, street signs, or store signs
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7. Doing fine handwork like sewing, knitting, crocheting or carpentry
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8. Writing checks or filling out forms
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9. Playing games like bingo, dominos, card games
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10. Taking part in sports like bowling, golf, tennis
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11. Cooking
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12. Watching television
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13. Driving during the day
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14. Driving at night
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Goldberg Depression Test (PHQ-9)
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Encounter
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Type
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Please complete the following...
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How often have you been bothered by any of the following problems over the last 2 weeks? All results are completely private
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1. Little interest of pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
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7. Trouble concentrating on things, such as reading the newspaper or watching television
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8. Moving or speaking so slowly that other people could have noticed
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9. Thoughts that you would be better off dead, or of hurting yourself
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10. If you've had any days with issues above, how difficult have these problems made it for you at work, home, school, other?
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10. Cont.... at work, home, school, other?
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END OF QUESTIONAIRRE'S
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Vital Signs
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