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Templates→Healthcare→Diabetes Self-Management Assessment

Diabetes Self-Management Assessment

Evaluate how patients are managing their diabetes at home, including blood sugar monitoring, diet adherence, and medication compliance. Supports care plan adjustments and education.

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Diabetes Self-Management Assessment

This assessment helps us understand how you are managing your diabetes day to day so we can support you better.

Patient Name*

Type of Diabetes*

Type 1Type 2GestationalPre-diabetes

How often do you check your blood sugar at home?*

Multiple times dailyOnce dailyA few times per weekRarely or never

Most Recent Fasting Blood Sugar Reading (if known)

How would you rate your adherence to your diabetes diet?*

Excellent — follow it consistentlyGood — mostly follow itFair — sometimes strugglePoor — rarely follow it

Are you taking your diabetes medications as prescribed?*

Yes — consistentlySometimes miss dosesFrequently miss dosesNot on medication

How many days per week do you exercise?

0 days1–2 days3–4 days5 or more days

Challenges With Managing Your Diabetes

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views1

healthcarediabetesendocrinologychronic diseaseself-management

Diabetes Self-Management Assessment - Free Healthcare Template | ZenBuild | ZenBuild