Diabetes Management Acknowledgement
Please complete this form to confirm your understanding and commitment to your diabetes management plan.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Diabetes
*
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Other
Please select the diabetes management practices you follow:
*
Regular blood glucose monitoring
Medication/insulin as prescribed
Healthy eating plan
Physical activity/exercise
Regular doctor appointments
Other
How confident are you in managing your diabetes on a daily basis?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Have you received education or training on diabetes self-management?
*
Yes
No
Please describe any challenges or concerns you have regarding your diabetes management:
Signature (please sign below to acknowledge your understanding and commitment)
*
Submit Acknowledgement
Submit Acknowledgement
Should be Empty: