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Diabetes Mellitus Type 1 and 2
Diabetes Mellitus (DM) is characterized by abnormal sugar metabolism, causing hyperglycemia (high blood sugar). Chronic hyperglycemia adversely affects the body. In the vascular system, there can be events such as strokes and heart attacks caused by atherosclerosis. There can also be renal disease, peripheral neuropathy, and blindness. In the United States, DM is a leading cause of end stage kidney disease, leg amputations, and blindness. Type 1 diabetes, formerly called juvenile-onset or insulin dependent (IDDM), has a peak age at onset of 12 years old. It is unusual to begin after age 40. Type 1 DM is due to beta cell destruction so that no insulin is produced and must be replaced by insulin injections. Symptoms include excessive thirst, excessive urination, and weight loss. Type 2 diabetes was formerly called adult-onset or non-insulin dependent (NIDDM). Type 2 DM is characterized by 1) variable degrees of resistance to the action of insulin, 2) impaired insulin secretion by the beta cells, or 3) excess glucose production. It usually develops over the age of 30, but its incidence is increasing in obese children and adolescents. Most of Type 2 patients are obese. Many have excessive thirst or urination, but most have no symptoms. Type 2 is initially treated with diet and exercise. If less calorie intake and more exercise does not result in blood glucose control, oral medication is added. Some oral medications include sulfonylureas, alpha-glucosidase inhibitors, thiazolidinedione, metformin, and repaglinide. Type 2 may also require insulin in the later stages. Secondary diabetes can result from pancreatic disease, hormonal
syndromes (Cushing’s syndrome), drug-induced disease (thiazide diuretics, steroids,
phenytoin) or those associated with syndromes such as hemochromatosis and
acromegaly. Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are also
termed subclinical or borderline diabetes. Patients generally have no symptoms. Many go
on to develop diabetes. There is also an increased risk of cardiovascular disease.
Gestational diabetes is diagnosed when glucose intolerance is discovered during a
pregnancy. It is associated with increased perinatal complications. Risk factors for the
development of gestational diabetes are older age, overweight, previous large or
stillborn babies, or positive family history of diabetes. Women with a history of
gestational diabetes have an increased risk of developing Type 2 diabetes (as high as
50% within 10 years and 70% within 20 years).
Producer _____________________________________________________
Phone____________________________ Fax ________________________

Email ________________________________________________________
Age/DOB________________ Sex__________________________________

Face Amount ________________________ Plan______________________
If your client has diabetes mellitus, please answer the following:
1. Please list date when first diagnosed:

2. How often does your client visit their physician? (also note date of last visit)

3. The client's diabetes is controlled by
Diet alone______________ Oral medication _______________________
(medication & doses) Insulin ______________________________ (amount of

4. Is your client on any other medications?
If yes, please give details

5. Please give the most recent blood sugar reading

6. Does your client monitor their own blood sugar?

7. If available, please give the most recent glycohemoglobin (HbA1c) or
fructosamine level.

8. Please check if your client has had any of the following:
Chest pain__________ Coronary artery disease ________ Overweight ______
Elevated lipids________ Protein in the urine________
Kidney disease________ Neuropathy___________ Black out spells_________
Retinopathy________ Hypertension________ Abnormal ECG__________

9. Has your client smoked cigarettes or used any form of tobacco in the last 5
years? If yes, please give details. _____________________________

10. Does your client have any other major health problems (ex: cancer, etc.)?
If yes, please give details __________________________________________
Please fax or scan your completed questionnaire
to Shaw American for your informal illustration.


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