FLOW SHEET Diabetes Care PATIENT
PROVIDER
Name :
Patient Test
Title:
Dr.
D.O.B :
March 8, 1988
Physician:
Zuchelkowski, Jan
Sex :
Female
Credentials:
MD
Clinic:
Millway Medical Centre Inc.
Phone#:
905-607-0017
ON OHIP Number : Chart Number :
9538
DIAGNOSIS Description
VITALS Assessment Date No Data To Display
Onset Date
Item
Value
Target
BSA
None
Head Circumference
None
Height
None
Height Percentile
None
Heart Rate
None
Height VS Weight Percentile
None
Respiration Rate
None
PEFR
None
Temperature
None
Waist Circumference
None
Weight
None
Weight Percentile
None
Blood Pressure
None
Blood Sugar
None
VISITS
Allergy
Medications No Data To Display
Immunization
No Data To Display
Injection No Data To Display
Problem List
No Data To Display
Social History No Data To Display
Category Tobacco
Family History No Data To Display
Comment
Date
PROVIDER
PATIENT
Title:
Dr.
Name :
Patient Test
Physician:
Zuchelkowski, Jan
D.O.B :
March 8, 1988
Credentials:
MD
Sex :
Female
Clinic:
Millway Medical Centre Inc.
ON OHIP Number :
Phone#:
905-607-0017
Chart Number :
9538
VISITS Procedure HbA1C (3 Month)
Target 0-7 %
Fasting Glucose (3 Month)
4-11 mmol/L
BLOOD GAS STUDIES (3 Month)
5-10 mmol/L
LDL Cholesterol (1 Year)
0-2 mmol/L
HDL Cholesterol (1 Year) TC:HDL-C Ratio (1 Year) Triglycerides (1 Year) ACR (1 Year)
0-4 0-2 mmol/L 0-2.8 mmol/L
eGFR (1 Year) Self Monitoring BG (3 Month) # of hypoglycemic episodes (3 Month) BP (3 Month) Height Weight BMI (20 Month) Waist Circumference (3 Month) Smoking Status Smoking Packs/Day Dilated Eye Exam Done (1 Year) Foot Exam Done (1 Year) Neurological Exam Done (1 Year) Fasting Glucose Meter Calibrated (1 Year) Education - Diabetes (1 Year) Education - Nutrition [Lipids]
18.5-24.9 0-88 CM
Patient Target
Base Line
24-April-2012
(1 Year) Education - Nutrition [diabetes] (1 Year) Motivational Counseling - Nutrition (3 Month) Motivational Counseling - Exercise (3 Month) Motivational Counseling - Smoking Cessation (3 Month) Motivational Counseling - Other (3 Month) Collaborative Goal Setting (3 Month) Self Management Challenges Y/N (3 Month) Self Management Challenges (3 Month) ASA Use Medication Management Erectile Dysfunction (1 Year) ECG (2 Year) Psychosocial Screening ANGIOTENSINCONVERTING ENZYME INHIBITORS BIGUANIDES SULFONYLUREAS ANTILIPEMIC AGENTS THIAZIDE DIURETICS
SIGNATURE :