History of present illness

DIABETES CLINIC INITIAL FLOW SHEET

Date:	DOB:
Name:	Sex: M F
Home Phone: Work Phone: Other Contact:	MRN: PCP:
Referred by:

HISTORY OF PRESENT ILLNESS
Duration of diabetes:

Prior hospitalizations/ER visits:

Previous therapy:

Present drug therapy:

Diet plan:

Quantity/d: Milk % Juice Soda

Nutrition	Breakfast	Snack	Lunch
Time
What Eaten
	Snack	Dinner	Snack
Time
What Eaten

Previous diabetes education:

SMBG:

Meter type:

Frequency:

Log book/diary: pre-breakfast pre-lunch pre-dinner HS

Exercise:
PAST MEDICAL HISTORY
Diabetic complications: Yes or No? Comments

Retinopathy (laser surgery, vitrectomy)

Nephropathy (microalbuminuria, proteinuria)

Neuropathy (gastroparesis, peripheral sensory)

Cardiovascular (angina, MI, CABG)

Cerebrovascular (TIA/stroke)

Peripheral vascular (bypass, amputation)

Associated Risk Factors Yes or No? Comments
Hypertension

Hyperlipidemia

Thyroid disease

Liver disease

Pancreatitis

Congestive heart failure

MEDICATIONS

MEDICATION ALLERGIES

FAMILY HISTORY (diabetes, cardiovascular events, hypertension, hyperlipidemia)
SOCIAL HISTORY

Occupation:	Language: English/Spanish Pt Ed Preference: English/Spanish
Marital Status: Children:	Alcohol: Tobacco:
Support System:	Insurance:

REVIEW OF SYSTEMS
Vision changes

Chest pain, dyspnea, orthopnea

N/V, early satiety, diarrhea, constipation

Sexual dysfunction, genital itching, yeast infections

Symptoms of hyperglycemia

Symptoms of hypoglycemia

Hypoglycemic unawareness

Pain in legs with walking

Lower extremity irritation (numbness, burning, pain, tingling, ulcers, etc.)

PHYSICAL EXAM



LABS

SMBG
FBS/HBA1c
BUN/SCr
AST/ALT
Urine Microalbumin
TSH

Total Cholesterol
Triglycerides
HDL
LDL
Non-HDL

ASSESSMENT

1. 
   Goal blood glucose:
   
2. 
   Goal HBA1c:
   
3. 
   Glycemic control status:
   
4. 
   Diabetic complications:
   
5. 
   Associated risk factors:
   
6. 
   Potential for drug/food/disease state/ETOH interactions:
   
7. 
   Potential for compliance/knowledge deficits:
   
8. 
   Patient’s perception/knowledge of illness:
   

Patient scored _________ on AACE knowledge test for sections on general knowledge, monitoring, and medications
PLAN

1. 
   Greater than ________ min of this 60-minute visit was spent on education: reviewed pathophysiology of diabetes, reinforced the rationale for intensive treatment and patient role in diabetes self-management. Reviewed diabetes signs and symptoms, when to call physician, self-monitoring glucose, and patient care goals.
   
2. 
   Diabetes regimen:
   
   1. 
      Continue:
      

2. 
   Changes:
   

3. 
   Return to diabetes clinic:
   
4. 
   Check fasting blood glucose and/or glycosylated hemoglobin:
   
5. 
   The patient’s medical record was reviewed.
   
6. 
   Referrals: