Alternative Insulin Delivery
Self-Assessment Tool

As our customer, we value your business and would like to know how we can better assist you with managing your diabetes. We have created a self-assessment screening tool to help you identify criteria for other insulin delivery methods.

When were you diagnosed with diabetes (year)?

How often do you test your blood sugar?

Bedtime

Do you take medication by mouth for your diabetes?

Yes

Comments:

Tell us about yourself:

How do you manage your diabetes:

Type of insulin injections:

Pen

Vial and Syringe

Insulin Pump

**If on pump, STOP - go to Tell Us About Your Diabetes

How many injections do you administer per day?

Long Acting:

Lantus: units

Levemer: units

NPH: units

**If only on Lantus or Levemer, STOP - go to Tell Us About Your Diabetes

Short Acting:

Humalog units:

Novolog units:

Apridra units:

Mix 70/30:

Mix 75/25:

Last 2 HbA1c lab results:

HbA1c Result: %

Date:

Year

Month

Day

HbA1c Result: %

Date:

Year

Month

Day

Tell us about your diabetes:

Do you usually have higher blood sugars in the morning than when you go to bed?

Yes

Do you have low blood sugars during the night (BS <70mg/dl)?

Yes

Do you have frequent hypoglycemia (BS <70mg/dl) throughout the day?

Yes

Number of times you have been below 50mg/dl within the past three months (estimate)?

Do you have hypoglycemic unawareness (you are not aware that your BS is low until you reach below 60mg/dl)?

Yes

Highest and lowest blood glucose levels within the last month?

Highest:

Lowest:

If you answered "Yes" to more than 3 of the above questions, you may be a candidate for an inuslin pump. Conact DMS at 1-888-738-7929 to discuss your options, or submit your name, email, and phone number below to have one of our representatives contact you.

Name: *

Email Address: *

Phone number: *