QUESTIONNAIRE

We at Healthy Agendas are concerned about your health.  As a follow up and in accordance

with the American Diabetes Association, we are requesting that you complete this

questionnaire and return it to us. All information is kept in your file and is confidential.
* Required fields

Healthy Agendas    
Name: *
   
E-mail: *
Date: *
   
     
1. Diet Management Yes No
    Since you received education, have you:    
    a. Started eating on a timely schedule
    b. Lost weight
     If yes, how much?
   
     
2. What is your most recent Hemoglobin A1c? %    
    Is that improved?
     
3. Exercise: please check statement that applies:    
    a. I was already exercising and have not changed my regimen
    b. I have begun an exercise program
      How many days per week? days    
      How long do your sessions last? mins    
    c. I chose not to begin exercising
     If you chose not to exercise, why?
   
   
     
4. Blood glucose monitoring: please check statement that applies:    
    a. There is no change in frequency
    b. I have started testing my blood glucose
    c. I do not test my blood glucose
      If you test, how frequently? times per day    
     
5. Since you came to Healthy Agendas, have you followed up with any of
    the healthcare providers listed below:
   
    a. Primary care physician/endocrinologist
    b. Dentist
    c. Podiatrist
    d. Eye Specialist
     
6. Do you check your feet daily?
     
7. Do you feel you could benefit from returning to our office for
    continued education?
    If yes, please call our office for an appointment at 954-475-4262    
    If not, what is the reason?  
   
    a. Financial
    b. Insurance status change
    c. Lack of motivation
    d. Doing well, do not need further education at this time
    e. Other    
     
     
We thank you for your time,

The Healthy Agendas Staff
140 SOUTH UNIVERSITY DRIVE,  SUITE D,  PLANTATION,  FLORIDA 33324       tel. 954-475-4262       fax. 954-475-4232