COMMUNITY DIABETIC ANNUAL REVIEW



NameDate of BirthNHS NumberBerkshire HealthcareFoundation trustMUSTWATERLOWBP R Arm L Arm Sitting StandingHeightWeightWaist circumferenceUrine sent for ACR Y/NSmoking statusAdvice Y/NDaily Alcohol Units =Advice Y/NExercise adviceAdvice Y/NDiet adviceAdvice Y/NInjection sitesY/NAttended eye screening Y/NAttended optician/eye clinic Y/NBlood sugar meter Y/NName of meterPatient injection/blood testing technique Y/NLast Hypo DateFlu/Pneumococcal up to date Y/NANNUAL BLOOD TESTS – Fasting chol profile, HBA1C, LFT, U/E, TFT, B12 if on Metformin YES/NODate TakenDEPRESSION SCORING PHQ 9 Required Y/NDuring the last month have you often been bothered by having little interest or pleasure in doing things???????? YES???????? NODuring the last month have you been bothered by feeling down, depressed or hopeless?????????? YES???????????? NOMEDICATION CHECKS GTN SPRAY Y/N number of times used in last week?--Does the patient understand what their prescribed medication is for? Y/NIs the patient taking their medication as prescribed Y/NDoes patient have written instructions on how to take their medication? Y/N (Frequency/timing etc)Nomad System Y/NAutomatic script Y/NRepeat script Y/NPatient stockpiling Y/NAre you adjusting your own medication Y/NFEET CHECK PULSES PRESENTVibration checkMonofilamentNeuropathy scoreRightDorsal pedis??? normal/abnormalPosterior tibia normal/abnormalNormal/abnormal /5LeftDorsal pedis normal/abnormalPosterior tibia normal/abnormalNormal/abnormal /5Total /10Vibration – use tuning fork on Left and Right IPJ jointNeuropathy monofilament check- check 1st, 3rd, 5th toe both feet and 1st, 5th MPJ both feetDocument findings on following foot chart.Right footLow/med/high riskRefer podiatry Y/NLeft FootLow/med/high riskFoot Care Advice Leaflet given Y/NPATIENT GOALS/ACTION PLANReview dateManagement Queries/Comments/referrals - for patients GP or Diabetic nurseNext Diabetic Annual review due DATE Copy of review proforma given to patients GP/Named Diabetic Nurse DATE ................
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