Welcome to the Living Better with Diabetes - Initial Patient Self-Assessment.  This questionnaire will take approximately 15 minutes to complete.  You will need to complete this questionnaire in a single session as it can not be saved and completed later.  By completing this questionnaire your pharmacist will be able to better understand your diabetes to better inform you or recommend changes that will benefit you in managing your diabetes.   Your responses are strictly confidential and will only be used by the pharmacist providing diabetes consultations with you.

Once the questionnaire is finished please click submit.  A copy of the questions and your responses will be e-mailed to you.
*a red asterisk indicates a response is required
Diabetes Patient Self Assessment

Patient Consent

The information collected as part of this online self-assessment questionnaire contains confidential personal health information; therefore it is important for you to understand the privacy and security issues involved. All of your personal health information will be stored using state of the art secure technology to ensure security and confidentiality. Your employer will not receive any personal health information that will identify you as an individual. The pharmacist providing Chronic Disease Management Services will only receive a copy of your results to discuss with you during your consultation and MHCSI will use non-identifying data combined with others in a large statistical database for aggregate reporting only.

By clicking below, you are agreeing to the above statements and release your information to be used only as specified above.

Patient Information

First
Last
(example: Lawtons Drugs Main Street, Dartmouth; Sobeys Pharmacy Mumford Road, Halifax)

Demographics

History

Check all that apply
(If your height falls in between, please round up)
example: 175 lb.
Check all that apply
Check all that apply

Questionnaire

Having Diabetes means that you need to make choices about food, physical activity, and when and how to take medicines. You may need blood tests and other exams to monitor your Diabetes health status. You also need to do things to prevent problems related to your health, know how to cope with Diabetes, and make everyday management decisions.

The following questions are about the things you need to do to stay healthy with Diabetes. These questions ask about the things you do, how often you do them, how important they are to you and how sure you are about doing them.

Reducing Risks - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Reducing risks means that you are taking steps to prevent or reduce problems related to diabetes. This includes having eyes checked by an eye doctor, having feet checked by a health care provider, seeing a dentist, getting flu and/or pneumonia vaccinations, having blood pressure checked, having cholesterol and triglycerides checked, and not smoking. (Check all the following things that have happened within the past year.)

0 = Not Important, 10 = Very Important
0 = Not at all Likely, 10 = Very Likely
0 = Not Sure, 10 = Very Sure

Being Active - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Being active means you are taking part in doing things such as jogging, bicycling, golfing, gardening, or walking (without stopping) for at least 30 minutes most days of the week.

0 = Not Important, 10 = Very Important
0 = Note Sure, 10 = Very Sure

Healthy Eating - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Following an eating plan that is good for you includes: not eating too much, counting the amount of carbohydrates you eat, not eating too much fat, keeping an eye on and / or drinking less alcohol. It also means eating fruits, vegetables, whole grains, beans and other foods with high fiber. Following an eating plan that is good for you may also include reaching weight loss goals and limiting your intake of protein and salt you eat.

0 = Not Sure, 10 = Very Sure
0 = Not Important, 10 = Very Important

Taking Medication - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Taking medication means that you take medicines that have been prescribed by your Healthcare Provider to treat your Diabetes and other health conditions. These may be pills, insulin, creams, or other medicines that you inject. For the next several questions, please answer for all the medicines that you take.

check all that apply
check all that apply
0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Monitoring - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Monitoring for people with Diabetes means they regularly check blood sugar. Monitoring also includes checking your blood pressure, cholesterol, and weight. Here we will focus on blood sugar monitoring. Monitoring the level of your blood sugar means that you use a blood sugar meter to take a blood sugar reading. Monitoring may be done on your own or with the help of a Healthcare Provider.

0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Problem Solving - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Problem solving means coming up with ways to make everyday and/or challenging decisions to stay healthy with your Diabetes. When you make a decision about what to eat or how much to eat, choose which medicines to take, decide whether to take a walk, or determine how you are going to make changes to your routine to help your Diabetes, you are problem solving. For most situations, this means figuring out the problem, finding a way to deal with it and thinking about what may prevent you from solving the problem.

0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Healthy Coping - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Healthy coping is having ways to help yourself or knowing when and how to seek help when you are overwhelmed by your Diabetes. Every person with Diabetes has to deal with stress, strong emotions or family situations that can make it hard to manage their Diabetes. How you feel and your quality of life can be affected by emotional and social problems.

0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Goal Setting

Self-Efficacy for Diabetes - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly at the present time.

0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident

Workplace Productivity and Impairment Score

The following questions ask about the effect of your diabetes on your ability to work and perform regular activities.

(Include hours you missed on sick days, times you went in late, left early, etc., because of your diabetes. Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
0 = Diabetes had no effect on my work, 10 = Diabetes completely prevented me from working
0 = Diabetes has no effect on my daily activities, 10 = Diabetes completely prevented me from doing my daily activities
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