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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