INTAKE TIMELINE
Dive, Dance, & Diet
First contact: We ask you to fill out the Intake forms as carefully as possible. While on the telephone you will be asked to E-mail the phone agent to confirm your email can receive documents back from us for intake and so on. Also during the call you will be directed to the this website for additional Q&A. The agent will talk you through the importance of membership in DAN to make sure you are safe while diving. He sends you forms for completion and then recommends you take them next-day to discuss this with your physician.
We expect a letter from your GP or endocrinologist that you can travel (DAN forms includes a simple version of this Physician Release) with direction to travel with the appropriate supplies. If not received back from you in timely fashion, the agent will follow-up by telephone to make sure of the completion of every detail. That will provide time to acquire deposits for room, meals and dive classes. Along with proof of membership in DAN, our forms must be approved before travel.
DAN Membership https://apps.dan.org/scuba-dive-insurance/?a=memberinfo
Intake Forms (Diabetesretreats.com) Please print then after you have completed them scan or photograph for subsequent emailing to our team :
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Remaining payments, in advance of the retreat, are due 30 days prior to arrival. You can use our recommended Gift Card or the same Credit Card you used to secure deposits and air travel.
New Patient Medical History Form Please complete the following questionnaire prior to your appointment with the physician. This information is very important to us for your care so please answer all the sections as accurately as possible. General Information Patient Name: ________________________________________________ Date of Birth: _____________________________ Age: ______________ Today’s Date: _________________ Name of Person Completing Form: ________________________________ Relationship: __________________ When did your diabetes start? ______________________________________________________________________ Any labs/x-rays for this problem? No Yes _________________ Have you been seen by an endocrinologist recently? No Yes Doctor’s Name: _________________ Family History regarding diabetes: __________________________________________________________________ _______________________________________________________________________________________________________ Patient Medical History: Hospitalizations or ER visits? No Yes List: _____________________________ _______________________________________________________________________________________________________ Surgeries? No Yes List: __________________________________________________________________________ Major/Chronic medical problems? No Yes Explain: _____________________________________________ Diet History/weight concerns: _________________________________________________________________
Clinical Trials Intake INSTRUCTIONS: This information will not be reused or disclosed to any other person or entity, except as required by law. The information you will provide will be stored in our files for a period not to exceed ten (10) years. If you give us permission, even if you are not eligible, we would like to keep your information in our files. CONSENT TO ALLOW TO BE CONTACTED FOR CLINICAL TRIALS AT RETREAT LOCATION: I, (Print Name) ________________________________________agree to be contacted by the Stem Cell Physician and or Staff regarding future clinical trials for which I may be eligible. I also agree and consent that my name and contact information may be provided to other departments at the Diabetes Retreat for the purpose of clinical trial information and/or eligibility screening. Signature: _____________________________ Date:# __________ >Hypoglycemia: 1. Do you suffer from frequent low blood sugar that result in loss of consciousness? Yes No 2. Do you have hypoglycemia unawareness? (Inability to sense when blood sugar is low) Yes No 3. Have you ever needed help from someone else to recognize a low blood sugar? Yes No 4. If you answered, “yes” to the previous question, how many times has this occurred in the last 12 months____ 5. Have you ever needed help from someone else to treat a low blood sugar? Yes No 6. If you answered, “yes” to the previous question, how many times has this occurred in the last 12 months?___ 7. Have you ever needed glucagon injections to treat a low blood sugar? Yes No 8. If you answered, “yes” to the previous question, how many times has this occurred in the last 12 months?___ 9. Have you ever been taken to an Emergency Room or had an ambulance called for you in order to treat a low blood sugar? Yes No 10. If you answered, “yes” to question 9, how many times has this occurred in the last 12 months?___ >Diabetes Management 11. Are you under the care of an endocrinologist or diabetes specialist ? Yes No 12. If yes, how many times have you visited him/her in the past year? _______________ 13. Has your endocrinologist measured your C-peptide recently? Yes No 14. If you have answered, “yes” to question 13.provide: Fasting C-peptide result:____________ Date:________ 15. What was your last HBA1C result?____________________ Date:________________ 16. How many times a day do you test your blood sugars? ___________________ 17. How do you administer your Insulin?__________________ Insulin Injections ________ Insulin Pump _________ 18. If you use insulin injections, please answer the following questions? 19. What is the average BASAL INSULIN that you require per day? ________________ 20. What is the average BOLUS INSULIN that you use per day? __________________