DIABETES WELLNESS QUESTIONAIRE Question Title * 1. Name Question Title * 2. Date of Birth Question Title * 3. Do you have a regular walking or exercise routine? Yes No Question Title * 4. How many times a week do you exercise? Question Title * 5. If yes, what kind of exercise routine? Question Title * 6. On a scale of 1-10, with 10 being excellent, how would you rate your dietary adherence? 1 2 3 4 5 6 7 8 9 10 Question Title * 7. Would you like us to schedule a dietitian consultation for you? Yes No Question Title * 8. What do you struggle with the most when it comes to your diet? Question Title * 9. What is the name of your eye doctor? Question Title * 10. Last Eye Appointment Question Title * 11. Have you been prescribed a glucometer to check your blood sugar levels? Yes No Question Title * 12. Do you check your blood sugar levels? Yes No Question Title * 13. If yes, how often? Question Title * 14. Average Reading of Recent Blood Sugar Question Title * 15. Last A1C Level Question Title * 16. Do you regularly check your blood pressure? Yes No Question Title * 17. Recent Blood Pressure Reading Question Title * 18. What is your blood pressure target? Question Title * 19. Do you regularly check your foot health? Yes No Question Title * 20. Have you had any chest pain or heart issues since your last visit? Yes No Question Title * 21. Have you quit any medications since your last visit? Yes No Question Title * 22. Have you run out of any medications since your last visit? Yes No Done
