Diabetes Education Referral (yearly) Nutrition Counselling Referral (yearly) Smoking Counseling 7/27/2001. Goodman Diabetes Service Outpatient Flow Sheet …
Name: MR: DOB:
Goodman Diabetes Service Outpatient Flow Sheet
Date
Check if done or record result
Diabetes Control Review Blood Sugar Log Hypoglycemia/DKA Inquiry Complications Monitoring Dilated Eye Exam yearly Foot Exam q 3 months
Check if High Risk Sensory Vascular
Education Issues Diabetes Education Referral yearly Nutrition Counselling Referral yearly Smoking Counseling Pre-Pregnancy Counseling Driving Counseling Labs Glucose Hemoglobin A1c q 3-6 months Hemoglobin/Hematocrit BUN/Creatinine yearly U/A, Microalbumin yearly Total Cholesterol yearly Triglycerides yearly HDL yearly LDL yearly ALT/AST FT4/TSH yearly if Type 1 Therpeutic Interventions Vaccinations ASA if indicated
7/27/2001
Source:fafp.org
