Hypoglycemia Questionnaire

  • June 2020
  • PDF

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HYPOGLYCEMIA QUESTIONNAIRE No = 0

Mild = 1

Moderate = 2

Severe = 3

Crave sweets

0

1

2

3

Irritable if a meal is missed

0

1

2

3

Feel tired or weak if a meal is missed

0

1

2

3

Dizziness when standing suddenly

0

1

2

3

Frequent headaches

0

1

2

3

Poor memory (forgetful) or concentration

0

1

2

3

Feel tired an hour or so after eating

0

1

2

3

Heart palpitations

0

1

2

3

Feel shaky at times

0

1

2

3

Afternoon fatigue

0

1

2

3

Vision blurs on occasion

0

1

2

3

Depression or mood swings

0

1

2

3

Overweight

0

1

2

3

Frequently anxious or nervous

0

1

2

3

TOTAL ________

Scoring: Less than 5 = hypoglycemia is not a likely factor 6 to 15 = hypoglycemia is a likely factor Greater than 15 = hypoglycemia is extremely likely

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