Symptom Use and Behavior Self Assessment
Please fill out the Self Assessment form prior to this so that our staff has all your basic information first.
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Have you filled out the Self Assessment form yet? Please fill out the Self Assessment form prior to this so that our staff has all your basic information first. *
Name: *
How much of the day do you think about weight, body shape or size? *
What methods have you used to try to lose weight? *
Do you binge? How often? *
Do you restrict food? How often? *
Do you restrict insulin? How often? Do you restrict your fast acting and your basal (long acting) insulin? Please be as specific as possible; there is NO JUDGEMENT here! *
Do you count calories? If so do you have a calorie “limit”? *
Do you count carbs? If so do you have a carb “limit”? *
Do you ever feel guilty about what you have eaten? *
Are there certain foods or food groups that you avoid? What are they? *
What are your thoughts when you have eaten “forbidden foods”? *
What do you do after you have eaten “forbidden foods”? *
Are you correcting blood sugar readings above 200? *
If you answered "no" to the above question what BG number are you willing to start correcting with? *
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