|
Open writing:
|
|
|
Diabetes
|
Diabetes Type
• • •
|
|
Diabetes comments
|
Daily Blood Glucose Testing
• • •
|
|
Currently on Insulin Pump?
• • •
|
Is patient on a Glucose Sensor?
• • •
|
|
Midnight/2am BS
|
|
|
Breakfast Blood sugar
|
|
|
Lunch Blood sugars
|
|
|
Dinner BS
|
|
|
HS BS
|
How many times a day is patient injecting insulin?
• • •
|
|
A1c result %
|
Date of last A1c
|
|
|
|
|
Thyroid
|
Hypothyroidism comments
|
|
Last Thyroid labs
|
Date of last thyroid labs
|
|
Osteoporosis/osteopenia
|
Osteoporosis comments
|
|
Hyperlipidemia/Dyslipidemia
|
Hyperlipidemia comments
|
|
Hypogonadism
|
Hypogonadism comments
|
|
Hypertension
|
Hypertension comments
|
|
Vitamin D Deficiency
|
Vit D Defic comments
|
|
Vitamin B12 Deficiency
|
Vit B12 Def comments
|
|
Adrenal Insufficiency
|
Adrenal Insuff comments
|
|
Insulin Resistance/Dysmetabolic Syndrome
|
Insulin Resistance comments
|
|
Hyperparathyroid
|
Hyperparathyroid comments
|
|
Hypoparathyroidism
|
|
|
Obesity
|
Obesity comments
|
|
Pituitary Dysfunction
|
Pituitary Dysfunction comment
|
|
Pertinent Labs
|
|
