Diabetes Self-Management Assessment Form
Personal Information
Name
Date of Birth
Type of Diabetes
Type 1
Type 2
Gestational
Other
Self-Management Areas
Are you taking medication for diabetes?
Yes
No
If yes, please list medications and schedules
How often do you check your blood glucose levels?
Multiple times daily
Once daily
Several times a week
Rarely/Never
Usual Blood Glucose Range (mg/dL)
Do you follow a meal plan?
Yes
No
If yes, describe your meal plan
Do you exercise regularly?
Yes
No
If yes, describe type and frequency
Have you experienced hypoglycemia (low blood sugar)?
Yes
No
If yes, how do you manage it?
What challenges or concerns do you have about managing your diabetes?