Diabetes Self-Management Assessment

Diabetes Self-Management Assessment — Form Fields

This healthcare template includes 8 fields. Evaluate how patients are managing their diabetes at home, including blood sugar monitoring, diet adherence, and medication compliance. Supports care plan adjustments and education. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Type of Diabetes (multiple choice, required) — options: Type 1, Type 2, Gestational, Pre-diabetes
• How often do you check your blood sugar at home? (multiple choice, required) — options: Multiple times daily, Once daily, A few times per week, Rarely or never
• Most Recent Fasting Blood Sugar Reading (if known) (text, optional)
• How would you rate your adherence to your diabetes diet? (multiple choice, required) — options: Excellent — follow it consistently, Good — mostly follow it, Fair — sometimes struggle, Poor — rarely follow it
• Are you taking your diabetes medications as prescribed? (multiple choice, required) — options: Yes — consistently, Sometimes miss doses, Frequently miss doses, Not on medication
• How many days per week do you exercise? (multiple choice, optional) — options: 0 days, 1–2 days, 3–4 days, 5 or more days
• Challenges With Managing Your Diabetes (long text, optional)