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 ________________________________________________________ Client________________________________________________________ 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 units/day) 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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10. Does your client have any other major health problems (ex: cancer, etc.)?