Diabetes Care Flow Sheet -
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1DIABETES CARE FLOW SHEET
Patient Name:
Physician:
Allergies:
Date of Birth:
q Male q Female
Phone:
Diabetes Education: q Referred q Class Completed
DX:
Complications:
q Type 1
q Type 2
q None
q Nephropathy q Retinopathy
Insulin:
q Yes
q No
q Neuropathy
q Periph Vasc
q Other
Home Monitoring:
Oral Medication: q Yes
q Yes
q No
q No
Tests:
Date:
Date:
Date:
Date:
Height:
Weight: lb or kg
BMI: Goal: <25
Diet Counseling:
q
q
q
q
Blood Pressure: Goal: <130/80
/
/
/
/
Dilated Eye Exam (Annually):
q Normal
Date of Exam: _________________________
q Retinopathy
Doctor: _______________________________
q Other
Foot Exam:
q Normal
q Normal
q Normal
q Normal
q Abnormal
q Abnormal
q Abnormal
q Abnormal
q Referred
q Referred
q Referred
q Referred
Exercise Reminder: Goal: 30m x 5d
q
q
q
q
Depression Assessment:
q No
q No
q No
q No
During past month:
q Yes
q Yes
q Yes
q Yes
Bothered by feeling down, depressed or hopeless?
q Referred
q Referred
q Referred
q Referred
Little interest or pleasure doing things?
Smoker: q
Cessation Counseling: q
Yes
q
No
q
q
q
Labs:
Date/Result
Date/Result
Date/Result
Date/Result
A1C:
(Every 6M controlled)
(Every 3M not controlled)
Goal: <7.0%
Microalbumin (Annually):
Type of Test:
Microalbumin Creatine Ratio
q
Random
Microal Dipstick
Timed
q
q
q
Goal: <30ug/mg
ACE/ARB: q Yes q No
q
q
q
q
Name:
Nephrology Referral:
q
q
q
q
Fasting Lipid Profile (Annually)
Date/Result
Date/Result
Date/Result
Date/Result
Total Cholesterol:
Goal: <200 mg/dL
LDL:
Goal: <100 mg/dL
HDL:
Goal: <40 mg/dL men
Goal: <50 mg/dL women
Triglycerides:
Goal: <150 mg/dL
Flu Vaccine (Annually):
Pneumonia Vaccine: Last Date:
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