Diabetes Visit Template



Diabetes Visit Template

Name_________________________

Patient ID _____________________

Date__________

Subjective:

Problems with hypoglycemia in the last month? Yes No

Symptoms of Diabetes out of control with excessive thirst or urination in the last month?? Yes NO

Activity level –structured walking or exercise

______No activity

______ Mild activity 1-2 times a week

______Moderate activity 3-4 times a week

______ Regular activity 5-7 times a week

Diet intake

_____low fat

_____ Moderate fat

_____High fat

Produce serving intake

______ Less than 2 servings a day

______ 3-4 servings a day

______5 or more servings a day

Tobacco

_______ Current

_______Never

_______Former smoker

Weight____________

Blood Pressure______________

Foot examination Skin____________Monofilament ________ Distal Pulses

Carotid ____________

Heart___________

Labs

HgbA1c ________

Urine Microalbumin________

Cholesterol______ HDL cholesterol _______LDL Cholesterol_______ Triglycerides____

Last dilated retinal eye exam______

Assessment

Diabetes mellitus

______With Complications

_______Without Complications

______At goal for glucose control

_______Less than optimal control

Lipids

_____At or near goal for LDL

_____ Less than optimal lipid management

Blood Pressure

______At or near target goal

______Less than optimal BP control

Plan:

Discussed a review of Diabetes and its complications

Discussed strategies to minimize complications

Reviewed targets for control

Encouraged healthy lifestyle

Spent more than 50% of this 60 minute session counseling on diabetes management options.

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