Lifestyle Docs

Name * Sex * Date of Birth * Current Weight * Height *

Detailed Diabetes History

Do you have type 1, 1 1/2, or type 2 diabetes? * Age at diagnosis * How long have you had diabetes? * What medicines are you currently using? * Do you feel your diabetes is in good control? * Do you experience any side effects from your medications? * How often do you check your blood sugar? * Do you have an implantable glucose monitor or insulin pump? * Last HbA1c reading? * Are you using any other method currently to achieve diabetes/sugar control besides medications? * What was your weight when diagnosed with diabetes? * Do you feel your weight affects your diabetes control or amount of insulin needed? * What do you notice affects your diabetes or blood sugar control? Do you have kidney disease? * If known, please list your Creatinine level and GFR

Diabetic Health Goals

How interested are you in reversing diabetes or greatly reducing your medications? * Please list at least two reasons you would like get off of Insulin or other medications * How confident are you that you will succeed on your own? * How confident are you that you will succeed with support from Lifestyle Docs? * What is the most important change you would like to see by adopting a healthier lifestyle * Are there any unusual stress factors that may hinder your health efforts at this time? * Readiness Today *