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Patient referred to Enara Health for
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due to ______
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Comments
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Patient’s Primary purpose of visit:
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Labs:
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Significant Labs:
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Others
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Blood Glucose Log ______
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Hypoglycemic episodes: Yes/No
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If yes, comments
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Weight history
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Comments
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Assessment any comments
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Weight assessment:
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Comments
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Labs in range/out of range
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Comments
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DSME assessment:
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Education
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Resources provided:
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Motivation
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Importance of goal of diet changes
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Confidence goals can be achieved
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Obstacles to change:
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Barriers to learning:
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Participate in nutrition selfmanagement training
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Stage of change
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Desired measurable outcomes
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Patient's action Plan
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Smart goal
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Provided RD contact info and schedule f/up in___
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Pull up Lab from the History
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