Care Plan
Section A - How am I feeling?
(The patient will indicate the response that best fits their situation)
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How am I coping with my life with Diabetes?
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Overwhelmed |
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A bit bothered |
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Very well |
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How is my emotional wellbeing?
(See WHO 5 )
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Worse |
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Same |
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Better |
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Am I getting up at night to pass urine?
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3-4 times |
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Once or twice |
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Not at all |
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Am I more thirsty than usual?
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Very much so |
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A little more |
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No more |
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What is happening to my weight?
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Going up |
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Same |
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Going down |
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Is my shape changing? Is my waistband......
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Tighter |
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Same |
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Looser |
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How is my eyesight?
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Worse |
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Variable |
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Good |
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How are my Feet?
Do I have calluses?
Do I get pins and needles or pain?
Do I have any red areas?
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Poor condition |
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In need of attention |
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Good |
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How active am I
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Not at all |
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Quite |
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Very |
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If I smoke, how do I feel about this?
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Not Worried |
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A bit worried |
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Want to quit |
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Am I concerned about my sex life?
(Males - erections)
(Females - dryness and vaginal soreness)
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Yes |
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No |
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If I am testing my blood, what are my results telling me?
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Don't know |
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Not sure |
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In control |
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How often do I experience hypos per month?
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Often |
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Sometimes |
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Never |
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Have I had any admissions to hospital or ambulance call-outs (if yes - why?)
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What problems do I have with my medications?
Remembering to take them?
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Rarely take them |
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Take them half the time |
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Never Miss |
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If I am struggling to take my medicines, is this because of confusion over their use, side effects or other reasons? Please comment. |
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This Questionnaire can be downloaded from here.