Diabetes Care Record
New Patient Form

Please fill out and print the this form.

Patient Information

Name:		Male Female	Date Of Birth:
Address:				Date:

For Doctor's Use only

Patient Lab Review

Medication Review

Diet

Notes:

Exercise

Notes:

History of present illness

Diabetes diagnosis date:
FH of DM?
Previous Hospitalization for Diabetes?
Currently SMBG?	Yes No	If yes, how many times per day?
Average BG range:

Complication of diabetes

Visual Changes?	Yes No	Stomach Problems?	Yes No
Hypertension?	Yes No	Recurring Infection?	Yes No
Sexual Impairment?	Yes No	Numbness/tingling in hand and feet?	Yes No
Kidney/Renal Problems	Yes No

Peripheral Vascular disease

Preventive screenings

Dentist(cleaning every 6 months):	Yes No
Optometrist(every year):	Yes No
Influenza Vaccine(every year):	Yes No	Pneumococcal Vaccine(every Year):	Yes No
Date of last Monofilament:		Monofilament Test Score:
Appropriate footwear:	Yes No	Daily Foot Maintenance:	Yes No
Last Podiatrist Visit:		Sores/infection/Foot Abnormalities:
Men older then 49 years: FOBT, Colon/Sigmoidoscopy, DRE, PSA			Yes No
Women older then 34 years: Pap Smear, Mammogram			Yes No
Women older then 49 years: FOBT, Colon/Sigmoidoscopy			Yes No

Handouts and Discussion with Patient
For Doctor's Use Only

	What is Diabetes		Exercise Tips
	Food to Eat/Foods to Avoid		Sitter-cise program
	Proper Foot Care		smoker cessation if necessary
	Initiate Lab Flow Sheet		Perform monofilament foot exam
	Complication of Type 2 Diabetes		Glucerna
	Connection Between high cholesterol, high BP and diabetes metabolic Syndrome		diabetes necklace
	Preventive Screening		Calculate Framingham Risk
	Hypoglycemic Episodes

Notes

Follow up in _________ days
Fasting Yes No
Session Time: __________

Pharmacist _________________________________ Physician ______________________________