If your client has a history of Diabetes, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of first diagnosis ?  


   2.  How often does your client visit their physician ?  


       Date of last visit ?  


   3.  Your client's diabetes is controlled by: (select all that apply)

        Diet Alone
        Oral Medication  (medication & doses)
        Insulin  (amount of units/day


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  Most recent blood sugar reading: 



   6.  If available, most recent glycohemoglobin (HbA1c)
       or fructosamine level: 


   7.  Does your client monitor their own blood sugar ? Yes   No 


   8.  Please check if your client has any of the following:
        Chest Pain or Coronary Artery Disease
        Protein in the Urine
        Neuropathy
        Retinopathy
        Abnormal ECG
        Overweight
        Elevated Lipids
        Kidney Disease
        Black-Out Spells
        Hypertension


   9.  Has your client smoked cigarette in the last 12 months ? Yes 


  10.  Does your client have any major health problems ? Yes   No 

       (example: heart disease, etc.)

       If yes, give details: