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Doctor Assessments
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Diabetes Problem Areas
Diabetes Problem Areas
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Doctor Assessments
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Name of the patient
*
Name of the referring Doctor
Contact Number of Patient / Referring Doctor
*
Email Address
Date of Birth of Patient
*
Symptoms, Duration, Brief History and Diagnosis
1 Not having clear and concrete goals for your diabetes care?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
2 Feeling discouraged with your diabetes treatment plan?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
3 Feeling scared when you think about living with diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
4 Uncomfortable social situations related to your diabetes care (e.g. people telling you what to eat)?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
5 Feelings of deprivation regarding food and meals?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
6 Feeling depressed when you think about living with diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
7 Not knowing if your mood or feelings are related to your diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
8 Feeling overwhelmed by your diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
9 Worrying about low blood glucose reactions?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
10 Feeling angry when you think about living with diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
11 Feeling constantly concerned about food and eating?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
12 Worrying about the future and the possibility of serious complications?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
13 Feelings of guilt or anxiety when you get off track with your diabetes management?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
14 Not accepting your diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
15 Feeling unsatisfied with your diabetes physician?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
16 Feeling that diabetes is taking up too much of your mental and physical energy every day?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
17 Feeling alone with your diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
18 Feeling that your friends and family are not supportive of your diabetes management efforts?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
19 Coping with complications of diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
20 Feeling burned out by the constant effort needed to manage diabetes?
*
Not a problem
Minor problem
Moderate problem
Somewhat serious problem
Serious problem
Problem Areas In Diabetes (PAID) Scale (The scores for each item are summed, then multiplied by 1.25 to generate a total score out of 100. › Total scores of 40 and above: severe diabetes distress.4 › Individual items scored 3 or 4: moderate to severe distress;4 to be discussed during the appointment following completion of the questionnaire.)
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