ANDIAB2 Australian National Diabetes Information Audit and Benching Project

Centre ID: DC005
Patient ID (Optinal):
Sex:
Staff ID: 00500
Date of Birth:
Date of Patient Visit:
Initial Visit: No / Yes
Indigenous: No / Yes
DVA Patient: No / Yes

Diabetes Type and Management and Lifestyle Issues
Year of Diagnosis:
Type of Diabetes: Type 1 / Type 2 / GDM / Don't Know / Other
Management Method: Diet Only / Tablets / Insulin / Insulin and Tablets / Nil
If on insulin: Since (year):
Currently Pregnant: No / Yes
NDSS Member: No / Yes
Have you had a Flu Vaccination in the past 12 months? No / Yes
Physical Activity Sufficient Status: Sufficient / Insufficient / Sedentary
Smoking Status: Current Smoker / Past Smoker / Never Smoked
If a Current Smoker: Have you tried to stop smoking ? No / Yes
If a Past Smoker: Which of the following methods did you use ? :
Just Stopped: No Intervention: No / Yes
Hypnosis: No / Yes
Medication: No / Yes
Acupuncture: No / Yes
Nicotine Replacement: No / Yes
Other: No / Yes

Patient Self Care Practices - Diet
Do you have difficulties following your prescribed diet? No / Yes
I don't have enough time to prepare healthy meals? No / Yes
It costs too much to eat well? No / Yes
I don't know what foods are best to eat? No / Yes
I eat out a lot and find it hard to eat well? No / Yes

If Yes - which of the following apply?:
It is not a priority, I have more important things to do?
No / Yes
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If Type 1 - It is too hard to count carbs - weigh food?
No / Yes

Assessment
LipoHypertrophy Present: No / Yes / Not Relevant [Not on Insulin]
LipoAtrophy Present: No / Yes / Not Relevant [Not on Insulin]

Most Recent HbA1c (last 6 mths)
Glycated Hb Result: . %

Medication Use
Do you ever forget to take your medications? No / Yes
If Yes: How many times per week:

Are you careless at times about taking your medications? No / Yes

Do you sometimes stop taking your medications when you feel better? No / Yes

Do you sometimes stop taking your medications when you feel worse? No / Yes

Are you using a complementary therapy or dietary supplement or OTC Rx? No / Yes

Have you told your Dr or educator about using complementary, dietary supplement or OTC Rx? No / Yes

Health Professional Attendances

Has the patient attended any of the following Health Professionals in the last 12 months? :
Podiatrist - No / Yes
Psychologist - No / Yes
Ophthalmologist - No / Yes
Exercise Physiologist - No / Yes
Educator - No / Yes
Social Worker - No / Yes
Optometrist - No / Yes
Dietitian - No / Yes
Diabetes Specialist - No / Yes
Dentist - No / Yes

Quality of Life Assessment

Diabetes Distress Scale [DDS]:

A
Screening Scale Q1 :
Screening Scale Q2 :

B
Total DDS Score : .
Emotional Burden : .
Physician-related Distress: .
Regimen-related Distress: .
Interpersonal Distress: .
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DDS 17 Questionnaire Done:
No / Yes

Own Health State Rating [0-100]:


BCD - Over the past couple of weeks has the patient been:
Having restless or disturbed nights : No / Yes
Feeling unhappy or depressed : No / Yes
Feeling unable to overcome difficulties : No / Yes
Dissatisfied with their way of doing things: No / Yes

Treatment
Is the patient taking antidepressants : No / Yes
Psych. treatment / counselling - past : No / Yes
Psych. treatment / counselling - now : No / Yes