Diabetes Intake - Health Questionnaire Name * First Name Last Name Email * Date of Birth * MM DD YYYY Age * Type of Diabetes * Type 1 Type 2 For how long have you been diagnosed with Diabetes? What steps have you taken to manage your condition? What has proven effective? What is your current diet? Please be specific to each meal. Are you currently taking any supplements or medication for your Diabetes? Please list. What would you like to work on with your condition? What would you like to accomplish in the next 30 to 90 days? What are the main obstacles to making changes to your diet or lifestyle, if any? Please list. What is the greatest accomplishment you would like to reach from our coaching? Please list four things you LOVE about your life. Thank you! I look forward to working with you, and helping you with your Diabetes,Heather M. Rowe, CHC
