Type of diabetes: Type 1

Type 2 Other Date of Diagnosis: 14/05/2017 Addressograph

Risk factors, Co-morbidities Vaccinations Name: MRS T
CAD Neuropathy
Mental health Flu (annual):
PAD ED PCOS ___________________
-
(date) DOB: 1967
CVD Hypertension HIV Pneumococcus
CKD Dyslipidemia 20 cause (once, repeat if age >65):
HCN:
Retinopathy
Smoking (Date stopped: _____________________ ) ___________________
-
(date)
Date 05/14/2017 Date 05/15/2017 Date 05/17/2017 Date
Self-management
Patient Goals Wound management Blood glucose control Blood glucose control
Barriers to Self-management Affraid to do self wound management Dont know how to do self monitoring blood glucose Do not have blood glucose test instruments

Self-management Education Use sandals Blood glucose test education Buy the instrument

Physical activity:
Aerobic 150 min/wk Resistance 2-3 times/wk
30 min - 30 min
Pre-conception counselling - - -

Weight/WC 55kg (BMI=22,08) 55kg (BMI=22,08) 55kg (BMI=22,08)

Glycemia
A1C: Target 7% or ______________________ - - -

Hypoglycemia - - -

Driving counselling - - -

SMBG (if applicable): B L D B L D B L D B L D

Pre-prandial: 4-7 2-hr post-prandial: 5-10
Glucose meter/lab comparison (annual) - - 125 mg/d

BP(target <130/80) 130/90 130/80 130/90

Cholesterol (annual; each visit if abnormal)

LDL-C - - -

HDL-C - - -

TG - - -

Non-HDL-C - - -

ApoB - - -

Nephropathy (annual; each visit if abnormal)

ACR - - -

eGFR - - -

Retinopathy (annual) Blurred vision Blurred vision Blurred Vision

Neuropathy
sensation pulses sensation pulses sensation pulses sensation pulses
Foot exam (annual; each visit if abnormal) lesions lesions lesions
lesions
no symptoms no symptoms
no symptoms
no symptoms
Other (ED, GI) symptoms: symptoms: symptoms: symptoms:
______________________ ______________________ ______________________ ______________________
CAD/PAD/CVD
no symptoms no symptoms
no symptoms
no symptoms
Symptoms symptoms: symptoms: symptoms: symptoms:
______________________ ______________________ ______________________ ______________________
ECG: baseline & q2 years if indicated Date: - Result: =
if 40 yrs;
yes Date assessed: _________________
14/05/2017

Statin >30 yrs and >15 yrs duration; or not indicated

end organ damage declined
if >55 yrs; yes Date assessed: _________________
14/05/2017

ACEi/ARB end organ damage; or not indicated

ACR >2.0 (even in the absence of hypertension) declined
Other (e.g. hospitalization, illness)
Plan
Insulin 16 IU Insulin 16 IU Insulin 16 IU

Medication Changes

ECG Funduscopy Lipid profile

Investigations

Referrals Ophtalmologist

Follow-up

guidelines.diabetes.ca
Copyright 2013 Canadian Diabetes Association diabetes.ca | 1-800-BANTING (226-8464)
 Type of diabetes: Type 1 Type 2 Other Date of Diagnosis: Addressograph
Risk factors, Co-morbidities Vaccinations Name:
CAD Neuropathy Mental health Flu (annual):
PAD ED PCOS ___________________ (date) DOB:
CVD Hypertension HIV Pneumococcus
CKD Dyslipidemia 20 cause (once, repeat if age >65):
HCN:
Retinopathy Smoking (Date stopped: _____________________ ) ___________________ (date)
Date Date Date Date
Self-management
Patient Goals
Barriers to Self-management
Self-management Education
Physical activity:
Aerobic 150 min/wk Resistance 2-3 times/wk
Pre-conception counselling
Weight/WC
Glycemia
A1C: Target 7% or ______________________
Hypoglycemia
Driving counselling
SMBG (if applicable): B L D B L D B L D B L D
Pre-prandial: 4-7 2-hr post-prandial: 5-10
Glucose meter/lab comparison (annual)
BP(target <130/80)
Cholesterol (annual; each visit if abnormal)
LDL-C
HDL-C
TG
Non-HDL-C
ApoB
Nephropathy (annual; each visit if abnormal)
ACR
eGFR
Retinopathy (annual)
Neuropathy
sensation pulses sensation pulses sensation pulses sensation pulses
Foot exam (annual; each visit if abnormal) lesions lesions lesions lesions
no symptoms no symptoms no symptoms no symptoms
Other (ED, GI) symptoms: symptoms: symptoms: symptoms:
______________________ ______________________ ______________________ ______________________
CAD/PAD/CVD
no symptoms no symptoms no symptoms no symptoms
Symptoms symptoms: symptoms: symptoms: symptoms:
______________________ ______________________ ______________________ ______________________
ECG: baseline & q2 years if indicated Date: Result:
if 40 yrs; yes Date assessed: _________________
Statin >30 yrs and >15 yrs duration; or not indicated
end organ damage declined
if >55 yrs; yes Date assessed: _________________
ACEi/ARB end organ damage; or not indicated
ACR >2.0 (even in the absence of hypertension) declined
Other (e.g. hospitalization, illness)
Plan

Medication Changes

Investigations

Referrals
Follow-up

guidelines.diabetes.ca
Copyright 2013 Canadian Diabetes Association diabetes.ca | 1-800-BANTING (226-8464)