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
