Diabetic Meal Programs, Diabetic Meal Plans, Meals for Diabetics

E-mail Address: *
Do you have any of the following illnesses or history of illnesses that have made you change the food you eat?
Diabetes: if yes, please answer questions below	Yes No
Do you see a neurologist?	Yes No
Do you see an ophthalmologist?	Yes No
Do you take insulin?	Yes No
Do you take an oral hypoglycemic?	Yes No
How often do you have your HgA1C taken?	Every 3 months Twice a year Once a year Never Don't Know
Do you see a nephrologist?	Yes No
Do you see a cardiologist?	Yes No
How often do you visit the dentist?	Never Occasionally When I have problems Twice a year
Kidney Disease:	Yes No
Hypertension:	Yes No
Heart Failure/Disease:	Yes No
Stroke:	Yes No
Arthritis:	Yes No
High Cholesterol:	Yes No
Chewing Difficulties:	Yes No
Osteoporosis:	Yes No
Food Allergies:	Yes No
Other:
Are you on any special diets for medical reasons? If on a special diet(s), check all that apply.
Reduced Sodium /Salt:	Yes No
Reduced Sugar:	Yes No
Higher Calorie Diet:	Yes No
Reduced Calorie Diet:	Yes No
Soft Diet/Foods:	Yes No
Other:
Are you taking medication(s) for any of the following diagnoses?
Diabetes/High blood Sugar:	Yes No
High Blood Pressure:	Yes No
High Cholesterol:	Yes No
Anxiety:	Yes No
Depression:	Yes No
Other Medical reasons:
Who do you live with?
What is your current marital status?	Single Married Widow/Widower Separated Divorced
Do you need assistance with any of the following?	Shopping Bathing Walking Cooking Taking medication
Are you aware of the dietary changes to make in order to help control your blood sugar?	Yes No
If yes, are you currently following a diabetic diet as it was explained to you?	Yes No
Do you feel you need more information about how to change your diet for better blood sugar control?	Yes No
How often do you eat the following foods?
a. non-diabetic desserts	Daily 3x weekly 1x weekly 2x monthly 1x monthly Occasionally Never
b. non-diabetic beverages	Daily 3x weekly 1x weekly 2x monthly 1x monthly Occasionally Never
Do you think that you eat the right amount of fruits and vegetables now, or do you think you should eat more?	Right Amount Eat More
In general, would you say your health is?	Excellent Very good Good Fair Poor
In general, would you say your appetite is?	Excellent Very good Good Fair Poor
Have you gained 10 or more pounds in the last 6 months without trying?	Yes No
Have you lost 10 or more pounds in the last 6 months without trying?	Yes No
Are you currently following a special diet?	Yes No
If yes, where did you find out about this diet?	Physician Nurse Dietitian Family/Friend Media(TV, radio, newspapers, magazines) Other
Do you eat some fruits and vegetables every day?	Yes No
Briefly describe what you usually eat and drink during a typical day (including food eaten on weekends)
How many milk products do you consume every day?
Would you like us to forward this survey to your doctor?	Yes No, thanks
If yes, please provide your doctors name and address:
Would you like us to send you a reminder about retaking this survey to compare results?	Yes No, thanks
If yes, when?


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