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Primary Provider
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Best Phone Number to reach pt
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Date of last Office Visit
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Date of Last IP Hospitalization
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Reason for last hospitalization
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Date of last ED Visit
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Reason for last ED Visit
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Name of Patient support at home
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Patient Insurance Plan
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CPC+ Patient?
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ACO Patient?
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Reviewed medication list w/pt or MAR
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Reviewed Allergies?
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Is the patient seeing other MDs?
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Is the patient seeing the dietician?
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Name(s) of Specialist(s)
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Is the patient on hospice?
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Is the patient on Home Health?
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Does patient live in a Nursing Home?
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Prognosis
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Newly diagnosed this year?
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Type 1 Diabetes
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Type 2 Diabetes
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Depression
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Ketoacidosis (DKA)
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Eye Complications
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Nephropathy (Kidney Disease)
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Eye Complication Choices
• • •
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Neuropathy
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Gastroparesis
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Obesity
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HHNS
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Skin Complications
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High Blood Pressure
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Skin Complication Choices
• • •
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Other Chronic Conditions, please list
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Stroke
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Self Care
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Seeing eye doctor for eye exam
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Date of Last Eye Exam
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Taking home blood sugars
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Home blood sugar goal
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Last home finger stick post breakfast
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Last home fingerstick post dinner
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Last home finger stick post lunch
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Last LDL value
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Last HbA1c value
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LDL Goal
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HbA1c goal
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Current Tobacco User?
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If a current tobacco user, how much and often?
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Checking blood pressure at home?
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Last Home BP
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Blood Pressure Goal
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Checking Feet Regularly
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Foot complications
• • •
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Proper foot care eduation given
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Comments
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Does patient check weight regularly at home?
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Current weight
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BMI WNL?
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Weight Goal
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Plan for proper nutrition
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Plan for Exercise
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Side effects from medications
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If yes, what side effect(s)?
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Associated Symptoms
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Symptoms are usually well controlled
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Comments
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Blurred vision
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Comments
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Confusion
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Comments
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Dizziness
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Comments
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Excessive Sweating
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Comments
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Fatigue
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Comments:
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Headaches
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Comments
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Increased appetite
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Comments
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Increased thirst
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Comments
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Increased urination
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Comments
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Current Status
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Personal Goal #1
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Action Steps
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Personal Goal #2
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Action Steps
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Personal Goal #3
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Action Steps
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Does patient feel goals are attainable?
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Comments:
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Date of next Care Management Visit
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