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Marital Status: Single Married Divorced Widowed Separated
Source of referral: Self referred Physician/Provider Other
Referring/Primary Care Provider and telephone number:
White American Indian/Alaska Native
Asian Native Hawaiian/Pacific Islander Spanish/Latino/Hispanic
Please describe your reason(s) for Meeting with the Dietitian today:
Do you have any of the following nutrition related concerns?
Please list food intolerances or food allergies:
Have you previously attempted any diets to assist with the following problems?
blood glucose management (diabetes, prediabetes)
weight loss (please continue to next page)
If yes, please describe: _________________________________________________
Diet for other reason not previously mentioned: _____________________________
Have you at any time in the past met with another registered dietitian, or licensed nutritionist? Yes (when?) ________ No
Whose nutritional guidance do you value now, or have you valued in the past? ________________________________________________________________________
Do you follow any particular eating regimen/nutrition plan currently (please name or describe):
What are your goals with this plan? _________________________
Have you attempted any of the following diets for weight loss?:
(please mark all that apply and briefly describe)
Medical and Health Care Treatments for Weight Loss
Have you ever been advised by a doctor to limit your exercise in any way?
Has your weight changed in the past year? Yes No How much?
Do you use or have you used tobacco products? No Yes When did you quit?
What hobbies bring enjoyment to your life?
Please list all of your medications, prescription and OTC
Do you have any drug allergies or intolerances? What type of reactions did you experience?
What are your health care goals and how can we facilitate those goals?
Have you previously had any diabetes education? Yes (when where?)
If yes, did you find this helpful? Yes No Do you current check your own blood sugars with a home glucose meter? ?Yes ?No If yes: Do you know the name of your meter? _______________________
How old is the meter you current use? ________________________ Do you like your current meter? ?Yes ?No How often do you current check your blood sugars? ______________ Do you keep a record of your blood sugars? ?Yes ?No Did you bring you glucose meter with you today? ?Yes ?No Do you know your blood sugar number goals? ?Yes ?No Fasting goals: _______ 2 hours after meal goals:_______________
Are there any topics below you would like to discuss specifically today? Please mark all that apply
Nutritional Guidelines Medicines (by mouth, or via injection) Blood Sugar Monitoring Goals A1c test Cholesterol test goals Exercise Guidelines Foot Care Complications associated with Diabetes Other Concerns regarding diabetes Stress management Other ______________________________
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I want to thank all of you for having me here today. It is a real pleasure to meet with you and get a sense of the tradition of the Law and Medicine Center here at Case Western Reserve. There have been a lot of contributions made by this program over the last fifty years, but I am here to tell you that we need innovative ideas in law and medicine, and we need them more than ever in health policy.