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Gestational Diabetes Assessment Form: Date

This document contains a gestational diabetes assessment form for a patient. It collects information about the patient's general health history, gestational diabetes history, exercise habits, eating habits, social history, and vital signs. It includes sections on the patient's name, contact details, medical history, current medications, pregnancy history, family medical history, lifestyle factors like diet, exercise and social support systems, and concludes by collecting a physical exam including measurements of blood pressure, pulse, temperature and others. The form is 2 pages and collects both qualitative and quantitative information to assess risk factors and manage care for gestational diabetes.

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Jhon Lazaga
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157 views

Gestational Diabetes Assessment Form: Date

This document contains a gestational diabetes assessment form for a patient. It collects information about the patient's general health history, gestational diabetes history, exercise habits, eating habits, social history, and vital signs. It includes sections on the patient's name, contact details, medical history, current medications, pregnancy history, family medical history, lifestyle factors like diet, exercise and social support systems, and concludes by collecting a physical exam including measurements of blood pressure, pulse, temperature and others. The form is 2 pages and collects both qualitative and quantitative information to assess risk factors and manage care for gestational diabetes.

Uploaded by

Jhon Lazaga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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[GESTATIONAL DIABETES ASSESSMENT

FORM] DATE:

GENERAL INFORMATION:

Name: ________________________________________Date of Birth: ___________________Age: ___________


Address: ____________________________________________________________________________________
Contact Number: ________________In Case of Emergency, Contact Person & Number: ___________________
List any Food allergies to food or medication: ______________________________________________________
Doctor’s/health care provider’s name: ________________Civil Status: ________Religion:__________________
Health History (Any current health issues and history of surgery, hospitalization and injury):

Current Medications including Vitamins, minerals and herbals:


___________________________________________________________________________________________

GESTATIONAL DIABETES HISTORY:


Weeks Gestation: _________Number of Pregnancies: __________Number of Living Children: ______________
Had Gestational Diabetes in Previous Pregnancies? YES NO Any Miscarriage/Abortion? YES NO
If Yes to GDM, Check Treatment: Diet Oral Medication (I.e. Metformin) Insulin
If you had GDM, any problems with the infant? ____________________________________________________
Had family history of Diabetes? YES NO If yes, which family member? __________________________
Other major/chronic conditions in the family: _____________________________________________________
Do you have Polycystic Ovarian Syndrome? YES NO Last Menstrual Period:___________________

EXERCISE ACTIVITY:
Do you have regular exercise routine? YES NO Type of Exercise: _______________________________
_________________________________ How many times a week?___________ For how long? _____________
Describe your daily activity level:
Sedentary (sit most of the day) Light (desk-work) Moderate (on feet most of the day) Heavy (manual labor)
Do you have any abdominal pain or discomfort when exercising? YES NO Doesn’t exercise

EATING HABITS:
Current Height: _______________Current Weight: _________________ Pre-pregnancy Weight: ____________
Do you follow a specific meal plan? YES NO Who does the food shopping?______________________
Who does the cooking? _____________________ How many times a week do you eat out? _______________
Which meals are you most likely to eat more? Breakfast Lunch Dinner Snacks Bedtime
Do you read food labels? YES NO What do you look for? _____________________________________

Medical record Page 1 of 2


PLEASE LIST EXAMPLES OF THE TYPE AND AMOUNT OF FOODS YOU EAT EACH TIME:

Breakfast

AM Snack

Lunch

PM Snack

Dinner

Bedtime Snack

SOCIAL HISTORY:
Do others live at home with you? YES NO What are their relationship to you? ____________________
___________________________________________________________________________________________
Do you have anyone you would identify as your support person? YES NO If yes, who? _____________
Is there stress in your life? YES NO If yes, explain: ___________________________________________
Do you use tobacco products? YES NO If yes, how much? ____________________________________
Do you drink alcohol? YES NO If yes, how many drinks do you have in a week? ___________________

VITAL SIGNS and STATS


Result Normal Value Result Normal Value

Blood Pressure <140/90 mmHg FBS ≤95 mg/dl

Pulse Varies RBS 90 – 140 mg/dl


Temperature < 37.5 ˚C BMI < 30
Waist
Respiratory Rate Varies Varies
Circumference

PATIENT’S SIGNATURE: ________________________________ DATE: ________________

Interviewer Notes:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

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[GESTATIONAL DIABETES ASSESSMENT
FORM] DATE:

____________________________________________________________________________________________
_____________________________________________________________________________________

Medical record Page 1 of 2

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