Center for Diabetes Care

www.centerfordiabetescare.com

Diabetes Information Sheet

Visit Date (mm/dd/yy) _____/_____/_____ Dr. _____________________

General Patient Information ID Number _______________

Name: _________________________, ___________________, _____ Age: _____ Sex: _____ Civil Status: _____
(Last Name) (First Name) (MI)

Complete Address: _________________________________________ Contact No: ________________________

__________________________________________________________

Birth Date: ______________Religion: ________ Race: ______ Region: _____ Occupation: __________________

In Case of Emergency

Contact Person: _______________________________________ Relationship to Patient: ___________________

Address: _____________________________________________ Contact Numbers: _______________________

I. MEDICAL HISTORY
A. Background With Formal Consult/Education

Newly diagnosed diabetes No Formal Consult/Education

Date of diagnosis (mm/dd/yy)
____/____/____ Compliance
Total caloric requirement
Previously diagnosed diabetes _____________
Date of diagnosis (mm/dd/yy) Meals
____/____/____ _____________
Duration of diabetes Snacks
______________ _____________
Age at diagnosis CHO
______________ _____________
CHON
Did the patient suspect he/she had diabetes at the _____________
time of diagnosis? Yes Fats
_____ No _____ _____________

Type of Diabetes Physical Activity

Type 1 Type 2 GDM __ Sedentary (little or no exercise, desk job)
__ Light Active (light exercise/ sports 1-3
Others (Secondary) IGT/IFG days/wk)
__ Mod. Active (mod exercise/ sports 3-
__________________ 5days/wk)
__ Very Active (hard exercise/ sports 6-
7days/wk)
B. Diabetes Education
__ Extreme Active (hard daily exercise/ job)
Has the patient attended any diabetes education
session? Yes _____ No
__ Oral antidiabetic
_____
___ Sulfonylurea
__________________
C. Allergies ___ Metformin
__________________
D. Current Treatment (check all that ___ Acarbose
apply) __________________
___ TZD
Medical Nutrition Therapy __________________
-1-
 ___ Others: Specify
__________________

__ Insulin _______________________type,
units/day

-2-
E. Other Medical Conditions (check all that apply)

Condition Date Diagnosed Medications

Hypertension _____ ACE inhibitor ___________ mg/day

_____ ARB ___________ mg/day

_____ Others (Specify) ________________________ mg/day

______________________________ mg/day
Condition Date Diagnosed Medications
Dyslipidemia _____ Statin ___________ mg/day

_____ Fibrates ___________ mg/day

_____ Others (Specify) ________________________ mg/day

Others: Specify

F. Hospitalizations
DKA _____________ HHS ____________ Hypoglycemia ___________

Stroke______________ MI _____________ Angina ___________

Others(specify) ____________

G. Surgeries/Operations

Amputation ___ digital ___ BKA

Revascularization ___________________
Others (specify) ______________________

H. Family Diseases

Diabetes ___________ Hypertension ___________ CVD __________ Stroke __________

Cancer _____________ Asthma ___________ TB ___________

Family Members Affected:

F: Father M: Mother B: Brother S: Sister GF: Grand Father GM: Grand Mother
SD: other second degree relatives

I. OB GYNE History
G ___ P ___ (T ___ P ____ A ___ L ___)

No. of babies ≥ 8 lbs _____ No. of babies with congenital anomalies _____

Menopause: no _____ yes _____ Date: __________

PCOS (Date Diagnosed) ______________________

J. Personal History

Smoking (Ave sticks per day & duration) _______________________ Quit (When) ___________

Alcohol beverage (Ave bottles per day & duration)_______________________ Quit (When) ___________
K. Signs and symptoms and other pertinent review of systems:

Polyuria _________ Weight loss ________ Others (specify) __________________

Polydipsia Tingling sensation _______ _______________________________

Polyphagia Non-healing wound _________ _______________________________

II. INITIAL PHYSICAL EXAMINATION (Fill-up 1st column of Follow-up Assessment Form – Reference Data)
ABI:
BP: Brachial* __________ mmHg Time taken ________
Ankle* __________ mmHg *brachial & ankle BP should be taken on same side
Ratio __________

Deep Tendon Reflex: _____ Achilles tendon _____ knee

Pulses: DP* ______ PT* ______ Pop* ______

* pulses should be taken on the same side.

Vibratory sense: _____ present _____ absent

III. DIAGNOSIS:
Type 1 Type 2 GDM

Others ______________________________________

IV. CONFIRMED DIABETIC COMPLICATIONS*

*To be filled only when confirmed at any time during the surveillance period, (encircle the satisfied criteria)

Date/ Remarks
Retinopathy (indirect ophthalmoscopy)

Nephropathy

(spot / 24-hr / timed urine collection / + micral /

albuminuria on routine urinalysis)

Neuropathy

(sensory / motor deficits / ↓ DTR / ↓ vibratory

sense / + monofilament test / ↓ NCV)

Coronary artery disease (CAD)

(+ chest pain w/ or w/o diaphoresis / AbN ECG /

+ angiography)

Peripheral vascular disease (PVD)

(ABI<0.85 / + occlusion angiography)

 Cerebrovascular disease (CVD)

(+ paralysis / + infarct on CT Scan)

FOLLOW UP ASSESSMENT FORM

Name __________________________________________ Age _____ Sex _____ Height _____

Page _____
INITIAL VISIT/REFERENCE DATA
Date (mm/dd/yy) ___/___/___ ___/___/___ ___/___/___

FBS FBS FBS FBS

RBS RBS RBS RBS
Post Prandial Post Prandial Post Prandial Post Prandial
Progress notes
Polyuria
Polydipsia
Weight loss
Tingling sensation
Non-healing wound
Others (specify)

Physical Examination
Waist & Hip circ (cm)
Weight (kg) / BMI
BP
Heart rate
Respiratory rate
Temperature
HEENT & Neck
Chest & Lungs
Heart
Abdomen
Skin & Extremities
Neurological findings
PLANS
A. Medications
A. Oral antidiabetic __ same regimen __ same regimen __ same regimen
__ Sulfonylurea ___________ __ change to ___________ __ change to ______________ __ change to __________
__ Metformin _____________
__ AGI __________________ __ add ________________ __ add ___________________ __ add _______________
__ TZD __________________
__ Incretin _______________
__ Others ______________

B. Insulin (units/day) __ same regimen __ same regimen __ same regimen

__ Regular ______________ __ change to ___________ __ change to ___________ __ change to __________
__ Intermediate __________
__ Mixed _______________ __ add ________________ __ add ________________ __ add _______________
__ Long acting ___________
__ Others

C. Antihypertensive __ same regimen __ same regimen __ same regimen

__ ACE ________________ __ change to ___________ __ change to ___________ __ change to __________
__ ARB ________________
Others: __ add ________________ __ add ________________ __ add _______________

D. Lipid – control drugs __ same regimen __ same regimen __ same regimen

__ Statin _______________ __ change to ___________ __ change to ___________ __ change to __________
__ Fibrate ______________
Others __ add ________________ __ add ________________ __ add _______________
E. Other Medications

B. Diabetes Education
A, Introduction to Diabetes

B. Medical Nutrition Therapy __ same regimen __ same regimen __ same regimen

__ change to: __ change to: __ change to:
TCR ______
CHO______
CHON _______
Fats_______

C. Exercise
Kind of exercise
Mins/day
Frequency/week

D. Education on Complications

E. Drugs

F. Stress Management

G. SMBG

H. Self Care

I. Sick Days

J. Smoking Cessation

K. Other Concerns

C. Immunization
____ Influenza
____ Pneumococcal

D. Laboratories to be done / Monitoring

A1c
Lipid profile
Micral test
ECG
Others specify:
E. Referrals to be done
Other specialists: please specify

F. Follow – up Date

Diabetes Information Sheet

Laboratory Results

Name ___________________________________ Age _____ Sex _____ Height _____ Page _____

Date (mm/dd/yy) ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___

A1C

FBS/ RBS

OGTT

Cholesterol

HDL

LDL

Triglyceride

Creatinine

BUN

Uric Acid

SGPT

Hemoglobin

Hematocrit

WBC

Neutrophils

Lymphocytes

Urine pH

Specific gravity

Sugar

Albumin

Pus cells

RBC

Cast

Crystals

Bacteria

Yeast

Micral

24-hr creatinine clearance

24-hr urinary protein

GFR

Chest x-ray

ECG
2D Echo

Ultrasound