Diabetes Educator, Consulting Pharmacist


Short Health Assessment Questionnaire                                                          

 Please mark your answer.

  1. Do you have family history of diabetes?     Yes or No
  2. Are you taking insulin and/or diabetes medications?     Yes or No
  3. Do you have problems with your blood pressure?     Yes or No
  4. Do you take blood pressure medications?     Yes or No
  5. Do you have elevated cholesterol?     Yes or No
  6. Do your take cholesterol medications?     Yes or No
  7. Do you have a history of stroke or heart problems/surgeries?     Yes or No
  8. Do you take aspirin or blood thinners?     Yes or No
  9. Do you drink soda, fruit juices, and/or alcohol?     Yes or No
  10. Do you use Splenda or other artificial sweeteners?     Yes or No
  11. Do you feel under stress?     Yes or No
  12. Do you currently smoke or did you use to smoke?     Yes or Never
  13. Do you take vitamins?     Yes or No

           If yes, write the names ________________________________________________

If you answered yes to more than 3 of the above questions, please, consider a 30-minute evaluation of your health.

Write your age ____ height ______weight ____

Do you know your blood glucose level?     Yes or No

Do you know your insulin and/or leptin levels?     Yes or No

Do you know your Vitamin D level?     Yes or No

Do you exercise?     Yes or No

If yes how many times a week? __________

Do you eat fresh vegetables (not from a can) with each meal?     Yes or No

Do you get a good night’s sleep every day?     Yes or No

Thank you.