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Edit Clinical Notes AOHC - Diabetes Education
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Vital Signs
c Premature d e f g graph sheet
HT:
graph sheet
WT:
Add BP CM KG
percentile:
Mother's Stature
percentile:
Father's Stature
HT/WT:
percentile:
BMI:
percentile:
Add PEFR CM CM
Status:
BSA: graph sheet
Systolic
graph sheet
CM
WC:
BP:
Diastolic
Limb
Adult
/
graph sheet
HR:
BPM:
Rhythm:
graph sheet
RR:
BPM:
Desc:
graph sheet
T:
graph sheet
SpO2:
graph sheet
Cuff Size
PEFR:
graph BS: sheet Client / Visit Type
째C
Date 5
2
2013
^ DD/MM/YYYY
Desc:
Location:
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L/min
5
2
2013
^
DD/MM/YYYY
mmol/L
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Client Type:
Visit Type:
Referred by:
Other:
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History Diagnosed:
Type:
Newly Diagnosed Previously Diagnosed & Not seen within 2 Years
When do you do Self-Monitoring Glucose: Never Before meals 2 hours after meals Bedtime 3 AM Other
Other:
Type 1 Type 2 Diet Type 2 ADA Type 2 ADA & Insulin Type 2 Insulin Pre-diabetes
Blood SelfMonitoring Blood Glucose:
Blood Glucose Date Range:
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3 AM Other Frequency of Hypoglycemic Episodes:
6 Skipped meal Delayed meal Insufficient carbohydrate intake Increased/unplanned activity Problem with Medication/insulin dose
None Daily Several times/day Weekly Several times/week Monthly Several times/month
Do you Smoke?
Reasons for Hypoglycemic Episodes:
Are you trying to stop smoking?
Episodes: Hypoglycemic Date Range:
Smoking Packs/Day:
Wants help to stop smoking Not interested in stopping Stopped 6 months ago Stopped 1 year ago Stopped 1+ years ago
Yes No Used to
Number of Hypoglycemic
Smoking Status Date:
ASA Use: ASA Use: Yes No
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ASA Use Date:
6 ACE Inhibitor/ARB Use:
ACE Inhibitor/ARB Use: Yes No
5
ACE Inhibitor Date:
6 Erectile Dysfunction:
Erectile Dysfunction: Yes No
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Erectile Dysfunction Date:
Dilated Eye Exam Done: g c d e f
Neurological Exam done:
Dilated Eye Exam Date:
Foot Exam done:
c d e f g
Foot Exam Date:
c Neurological Exam Date: d e f g
Fasting Glucose Meter Calibration: g c d e f
Fasting Glucose Meter Calibration Date:
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Nutritional Risk Factors: Age: g c d e f Age Comments:
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Sepsis: g c d e f Sepsis Comments:
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6 Cognitive Deficit/Impairment: g c d e f Cognitive Deficit/Impairment Comments:
Cardiac Disease: g c d e f Cardiac Disease Comments:
5
5
6
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Fever: g c d e f Fever Comments:
Respiratory Disease: g c d e f Respiratory Disease Comments:
5
5
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Albumin<35: g c d e f Albumin<35 Comments:
Surgery/Procedures: g c d e f Surgery/Procedures Comments:
5
5
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Compromised Nutritional Status: g c d e f Compromised Nutritional Status Comments:
CVA: g c d e f CVA Comments:
5
5
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Severe Infection: g c d e f Severe Infection Comments:
Skin Breakdown/Wound: g c d e f Skin Breakdown/Wound Comments:
5
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Cancer: g c d e f Cancer Comments:
HIV: g c d e f HIV Comments:
6
GI Disorders/Diseases: g c d e f GI Disorders/Diseases Comments:
5
5
6
6
Diabetes: g c d e f Diabetes 5 Comments:
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6 Hypercholesterolemia: g c d e f Hypercholesterolemia Comments:
6 Dehydration: g c d e f Dehydration Comments:
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5
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Hypertrigylceridemia: g c d e f
Renal Failure: g c d e f
Hypertrigylceridemia Comments:
Renal Failure Comments:
Hypertension: g c d e f Hypertension Comments:
5
5
6
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Disordered Eating Patterns: g c d e f Disordered Eating Patterns Comments:
5
5
6
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Vitamin/Mineral Deficiency: g c d e f Vitamin/Mineral Deficiency Comments:
Eating Disorder: g c d e f Eating Disorder Comments:
5
5
6
6
Iron deficiency (without anemia): g c d e f Iron deficiency (without anemia) Comments:
Bulimia Nervosa: g c d e f Bulimia Nervosa Comments:
5
5
6
6
Iron deficinecy (anemia): g c d e f Iron deficinecy (anemia) Comments:
GERD: g c d e f GERD Comments:
Anorexia Nervosa: g c d e f Anorexia Nervosa Comments:
5
5
6
6
Binge Eating Disorder: Binge 5Eating Disorder Comments:
c d e f g 5
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6 Allergies: g c d e f Allergies Comments:
Obesity: g c d e f Obesity Comments:
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Intolerances: g c d e f Intolerances Comments:
Other Comments:
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Diabetes Care Education and Counseling
j Template View k l m i Narrative View n j k l m n Diabetes Education:
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Diabetes Education Completed? Yes No
Diabetes Education Handouts Provided? Yes No
6 Nutrition Lipids Education:
Nutrition Lipids Education Completed? Yes No
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Nutrition Lipids Handouts Provided? Yes No
6 Nutrition Diabetes Education:
Nutrtion Diabetes Education Completed? Yes No
Nutrition Diabetes Handouts Provided? Yes No
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Foot Care Education Completed? Yes No
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Follow Up Plan/to be discussed next time:
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