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Be careful, this is a persistent template so you
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must check all items for accuracy-Thanks!
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Diabetes?
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Type
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DM present since
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What DM symptoms?
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HBA1C Date and value
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LDL screening <100: Date and value
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Microalbuminuria Date and value
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Retinal Eye Exam: Date, result and provider
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Renal Manifestations
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Other Renal Manifestations(Specify)
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Ophthalmic Manifestations
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Other Ophthalmic Manifestations(Specify)
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Neurological Manifestations
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Other Neurol. Manifestations(Specify)
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Angiopathy Manifestations
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Other Angiopathy Manifestations(Specify)
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Arthropathy Manifestations
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Other Arthrop. Manifestations(Specify)
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Ulcer/Skin Conditions Manifestations
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Ulcers/Skin Conditions(Site of Ulcer(s))
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Other Conditions Manifestations
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Other Manifestations(Specify)
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more DM Free text
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Plan
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CAD?
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MI & Angina
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present since
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Current Treatment
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Previous treatment
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LDL screening: Date and Value
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It interferes with daily living...
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CAD associated conditions
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Regimen Effectiveness/Status
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CAD comments
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Plan
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Stroke/CVA?
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CVA occurred when?
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It interferes with daily living...
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CVA dominant, non dominant
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Regimen Effectiveness/Status
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Regimen Effectiveness/Status
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CVA Late effects
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CVA Free text
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Plan
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CHF?
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CHF present for
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CHF Complications
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LV EF% date and result
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It interferes with daily living...
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Regimen Effectiveness/Status
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CHF free text
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Plan
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Hypertension?
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Condition present how long?
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HTN present since
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It interferes with daily living...
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HTN Complications
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HTN free text
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Regimen Effectiveness/Status
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Plan
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COPD ?
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Condition present how long?
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COPD Details (R)
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Spirometry date and result
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Interferes with daily living?
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Regimen Effectiveness
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Complications of the condition
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Plan
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Cancer/Malignancy/CA?
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Type of Malignancy
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Malignancy free text
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malignancy present for
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Cancer Treatments to date
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Complications
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If METASTASIS, to what site?
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more malignancy free text
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Regimen Effectiveness/status
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Oncologic Plan
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Interferes with daily living?
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Renal/Kidney Disease
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Renal disease present how long?
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What stage of renal disease?
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ESRD Complications
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Renal disease associated conditions
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GFR or Creatinine/Date if available
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Treatment :
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Complications of the prescribed treatment
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Symptoms of the Kidney Disease
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Plan
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Comments
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Comments
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Other Condition 1
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Condition freetext
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find Disease/Condition alphabetic
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find Disease/Condition by system
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Complications of the condition
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Condition present how long?
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Interferes with daily living?
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Complications of the prescribed treatment
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Condition freetext
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Regimen Effectiveness
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Plan
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Other Condition 2
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Condition freetext
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find Disease/Condition alphabetic
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find Disease/Condition by system
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Complications of the condition
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Condition present how long?
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Interferes with daily living?
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Complications of the prescribed treatment
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Condition freetext
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Regimen Effectiveness/Status
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Plan
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Other Condition 3
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Condition freetext
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find Disease/Condition alphabetic
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find Disease/Condition by system
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Interferes with daily living?
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Condition present how long?
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Regimen Effectiveness/Status
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Complications of the prescribed treatment
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Condition freetext
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Associated symptoms
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Plan
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Other diagnoses
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Other Diagnoses
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**Medications reviewed and reconciled?
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Please say why not: (select)
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Please say why not: (free text)
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Overall Status
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Recommendations
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Next visit
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Referrals
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Comments
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