Diabetes Education Program Self-Referral Intake Questionnaire

The vision of our Diabetes Education Program (DEP) is to offer accessible diabetes education services that enable individuals and families to develop skills for effective self-management, leading to an improved quality of life. The DEP provides personalized guidance, up-to-date health information, and practical tools to help patients live well with diabetes.

Self-referrals are initially offered to attend our Introductory Group Class hosted by our Dietitian covering topics including "what is diabetes?", preventing complications, monitoring blood sugars, medications, healthy eating, exercise, etc. Each person will be provided with a glucometer (if required) and be given the opportunity to book a follow-up appointment.

Our website has more information including hours of operation. We are closed weekends and stat holidays.

Please answer these questions to request a Diabetes Education Program appointment. Our team will then contact you to offer a date/time for an appointment.

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First Name of the person (as shown on health card):

Last Name of the person(as shown on health card):

Date of Birth (DD/MM/YYYY):

Health Card # with version code (123456789-XX)

Gender (as shown on health card):?

Home Street Address:

City:

Postal Code (A2A 2A2) :

Province:

if out of country, which country:

This is required

Preferred contact phone number with area code:

If you would like to receive text or email reminders of your appointments, please enter your email and/or cell phone number below:

email:

cell phone number:

Family Doctor/Nurse Practitioner name and location: (i.e. Dr Roger Smith, Napanee) If you do not have a family doctor and are self-referring please leave this field blank.

Regarding the person requiring the appointment, what are you looking to get help with from this program :

Do you have an urgent concern that requires immediate contact by our Diabetes Educator?

Yes

Have you had been in a diabetes program before?

Yes

If Yes, where?

This is required

How do you manage your diabetes?

Diet/Lifestyle

Oral Medications (ex. Metformin, Jardiance, Rybelsus, etc.)

Non-Insulin Injections (ex. Ozempic, Mounjaro, etc.)

Insulin

Insulin-Pump

Other (please specify):

This is required

Where did you hear about our program?

Previous Client

Family/Friend

Website

Other (please specify):

This is required

Diabetes Education Program Self-Referral Intake Questionnaire

Page 1

First Name of the person (as shown on health card):

Last Name of the person(as shown on health card):

Date of Birth (DD/MM/YYYY):

Health Card # with version code (123456789-XX)

Gender (as shown on health card):?

Home Street Address:

City:

Postal Code (A2A 2A2) :

Province:

Preferred contact phone number with area code:

If you would like to receive text or email reminders of your appointments, please enter your email and/or cell phone number below:

Family Doctor/Nurse Practitioner name and location: (i.e. Dr Roger Smith, Napanee) If you do not have a family doctor and are self-referring please leave this field blank.

Regarding the person requiring the appointment, what are you looking to get help with from this program :

Do you have an urgent concern that requires immediate contact by our Diabetes Educator?

Have you had been in a diabetes program before?

How do you manage your diabetes?

Where did you hear about our program?

Any other information we should know regarding this appointment booking?