Office Forms Hypoglycemia Questionnaire
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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
870 POST ROAD, DARIEN, CT 06820
203-‐655-‐4494
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
870 POST ROAD, DARIEN, CT 06820
203-‐655-‐4494
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