3 Month Check In DSMES Name First Last PhoneEmail Which DSMES Classes did you attend? Select all that apply. Class 1 Class 2 Class 3 Class 4 Select the topic of the Smart Goal(s) you were focusing on. Select all that apply: Medication Management Physical Activity Healthy Eating Healthy Coping In your words, what were the SMART Goal(s) you were focusing on:How much of your goal have you completed so far? 0-25% 25%-50% 50%-75% 75%-100% How confident do you feel in your ability to accomplish your goal? Not confident Somewhat confident Confident Very confident What is your current A1C?A1C last checked date: MM slash DD slash YYYY How many glasses of water do you drink a day? 1-2 3-4 5-6 7+ Have you had your feet checked by a doctor? Yes No If Yes, when? MM slash DD slash YYYY Do you check your feet at home? Yes No If Yes, how many times a day? 1-2x 3-4x 5-6x 7+ Have you had an eye exam? Yes No Date MM slash DD slash YYYY Since the completion of the diabetes classes, approximately how much time have you spent each week on physical activity? 0-10 minutes per day 10-30 minutes per day 31-59 minutes per day 60+ minutes per day
