Assessment Surveys

Diabetes Maintenance Assessment

Careful management of diabetes is fundamental to good health.

To evaluate how well you are managing your diabetes, please complete the Diabetes Maintenance Assessment below.

 1. Do you control your blood sugar with diet and exercise?
    Yes    No
 2. During the last 4 weeks, have you been checking your blood sugar?
    Yes    No
 3. Have you had your A1C measured in the past 12 months?
    Yes    No
 4. Do you know your cholesterol and LDL level?
    Yes    No
 5. Have you had an eye exam in the past 12 months?
    Yes    No
 6. Do you do daily foot checks?
    Yes    No
 7. Has your doctor examined your feet in the last year?
    Yes    No
 8. Do you take aspirin daily?
    Yes    No
 9. Do you know your blood pressure?
    Yes    No
10. Do you get flu shots annually?
    Yes    No
11. Have you had a pneumonia vaccination in the past five years?
    Yes    No
 
 
Developed by Research Administration at Hartford Hospital
 

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