PLEASE PLACE PATIENT LABEL HERE OR FILL OUT

Patient Name: ___________________________________

Scripps Whittier Institute
La Jolla Main Line: (858) 626-5672/ Fax (858) 626-7111 MRN: _________________________________________
Rancho Bernardo (858) 605-7369/ Fax (858) 605-7292
Vista (760) 806-5863 / Fax (760) 806-5429

GESTATIONAL DIABETES
History & Assessment
Diabetes History Primary Care Provider __________________________
Do you have a family history of diabetes? Yes No If yes, who and what type __________
Do you have a previous history of gestational diabetes? Yes No
Did you have diabetes prior to pregnancy? Yes No
If yes, for how long? _____________________ Type of diabetes? _________________________
If you had diabetes prior to this pregnancy, did you receive preconception care and/or instruction
regarding diabetes and pregnancy? Yes No
Pregnancy History
How many weeks pregnant are you today? ________When is your expected due date?________

Have you been pregnant before? Yes No

Number of pregnancies ______________ Number of live births? _________________

How much did your babies weigh? ___________ Any premature babies? ____________________

Medical History
Check if you have any of the following medical conditions:
High blood pressure High cholesterol Depression
Please list other medical conditions you have: _____________________________________
Height_____________ Current Weight _____________ Pre-pregnancy weight _____________
Preconception A1C _____________ Date: _____________________
Exercise Profile
Do you exercise? Yes No If yes, what do you do? _____________________________
How often? _______________ If no, list reason or problems that prevent you from exercising:
____________________________________________________________________________
Smoking/Alcohol History
Do you smoke? Yes No If yes, how much? _______________________________________
Did you ever smoke? Yes No If yes, when did you stop? ___________________________
Do you drink alcohol? Yes No If yes, how much? _________________________________

(TURN OVER PLEASE)

GDM History and Assessment Form Rev. 03/02/10
Education Level
No formal education Some High School (7-11) Some College/Tech School
Elementary (1-6) High School Graduate/GED College Graduate

Preferred Reading Language  English  Spanish  Other __________________  Unknown

Race/Ethnicity
African/Somali African American American Indian/Alaskan Native
Caucasian/European Hispanic/Chicano/Cuban/Mexican/Puerto Rican/Latino
Asian/Chinese/Japanese/Korean/Pacific Islander Middle Eastern

Personal History
Do you work outside the home? Yes No Occupation? ___________________________Hours?_________
Who do you turn to when you need support? Family _______________  Friend_______________________
What causes you stress?________________________ What helps you to relax?____________________________

Do you follow a special diet? No Yes If yes, what diet? _____________________________________
Are you taking pre-natal vitamins? Yes No What is your calcium source? ____________________________
Please list the foods and amounts that you eat and drink on a typical day
Breakfast: ________________________________________________________Beverage ___________________

Snack: ___________________________________________________________Beverage ___________________

Lunch: __________________________________________________________ Beverage ___________________

Snack: ___________________________________________________________Beverage ___________________

Dinner: __________________________________________________________Beverage ___________________

Snack: ___________________________________________________________Beverage ___________________

Would you like to be contacted about upcoming Clinical Trials? Yes No
………………………………………………………………………………………………………………………….
Educator Use Only
Daily Nutritional Recommendations
Times B S L S D S
CHO
Grams Check materials provided
Starch GDM Diabetes Folder Meter _________
Fruit
Milk Stress Questionnaire Resource Guide
Veg.
Protein
Other _________________________________
Fat
Calories

Comments:___________________________________________________________________________
____________________________________________________________________________________
Visit Provider Signature: ________________________________________________Date: ___________

GDM History and Assessment Form Rev. 03/02/10