Diabetes Care Note
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Patient name: Vital Signs Date: Medical Record : □ Male □ Female Tobacco use: □ Yes □ No A1C:mg/dL WT: RR: Preprandial glucose:mg/dL HT: BP: Lipid: Totalmg/dL LDL HDL Triglycerides HR: Temp: Medications: Physical Exam Foot Exam Test Areas Head and neck: Lungs: Heart: Abdomen: Extremities: Neuro: Other (e.g., eye, dental): Indicate Presence (+) or Absence (-) of sensation in 5 areas using 10-gram monofilament Patient assessment — follow up as necessary (Check best answer) Have you visited an emergency room or urgent care office or been admitted to the hospital for treatment of diabetes problems since your last visit □ No □ Yes How many times a day do you test your blood sugar with your meter □1 □ 2 or more Do you have any trouble telling when you have low blood sugar □ No □ Yes How many times per week do you have low blood sugar during the day □0 □ 1 or more How many times per week do you have low blood sugar at night □0 □ 1 or more Do you have any problems with your medicines □ No □ Yes Have you noticed any problems with your eyes, feet, or skin since your l
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