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: 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? 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 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
