Modupe Aiyegbusi, MD - Publicforms

Please type in your Name *

Date of Birth *

I feel tired *

I feel Hungry *

I feel thirsty *

My vision is blurry *

I feel signs of neuropathy *

I find it hard to concentrate *

I feel depressed *

I feel anxious *

Issues and Concerns: Please check all that apply *

I cannot gain weight

I cannot lose weight

I find my diet very limiting

I'm finding it impossible to meet my blood sugar goals

My medication / injection schedule makes it difficult for me to work

Sometimes I skip my medication because I can't tolerate the side effects (upset stomach, water retention, rashes, dizziness)

Sometimes I skip my medication because it cost too much

My medication / injection schedule makes it difficult for me to socialize

List any other concerns

Results of my last A1c *

How many times do you test your blood sugar per day?

What are 3 factors that seem to raise your blood sugar?

What 3 factors seem to lower your blood sugar?

Any other patterns you have noticed?

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