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Referred by:
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PCP:
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Telehealth Visit
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Telehealth Appt- Video or Audio
• • •
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Patient location for Telehealth visit
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Open writing/why telehealth visit
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Open writing:
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Pre Diabetes
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Pre Diabetes Comments
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Insulin Resistance/Dysmetabolic Syndrome
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Insulin Resistance comments
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Hypoglycemia
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Hypoglycemia comments
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Diabetes
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Diabetes Type
• • •
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Diabetes comments
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Daily Blood Glucose Monitoring:
• • •
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How many times a day is patient injecting insulin?
• • •
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Currently on Insulin Pump?
• • •
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Is patient on a Glucose Sensor?
• • •
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Patient has hypoglycemia unawareness
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AM Fasting Blood sugars
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Breakfast Blood sugars
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Lunch Blood sugars
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Dinner Blood sugars
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Bedtime Blood sugars
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Overnight Blood sugars
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Last A1c result %
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Last A1c date
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Last Creat result
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Last Creat date
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Last GFR result
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Last GFR date
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ALB/CR Ratio
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ALB/CR Ratio Date Done
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Thyroid
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New Multiple Select
• • •
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Thyroid comments
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Last TSH was
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Last TSH date
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Last Free T4 was
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Last Free T4 date
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Last Free T3 was
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Last Free T3 date
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Osteoporosis/osteopenia
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Osteoporosis comments
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Hyperlipidemia/Dyslipidemia
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Hyperlipidemia comments
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Hypercholesterolemia
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Hypercholesterolemia comments
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Hypogonadism
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Hypogonadism comments
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Hypertension
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Hypertension comments
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Hypotension
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Hypotension comments
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Vitamin D Deficiency
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Vit D Defic comments
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Last Vit D result
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Last Vitamin D date
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Adrenal Insufficiency
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Primary or Secondary A.I
• • •
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Adrenal Insuff comments
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Cushing's Syndrome
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Cushing's Syndrome comments
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Pheochromocytoma
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Pheochromocytoma comments
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Diabetes Insipidus
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Diabetes Insipidus comments
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Hyperparathyroid
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Hyperparathyroid comments
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Hypercalcemia
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Hypercalcemia comments
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Obesity
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Obesity comments
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Pituitary Dysfunction
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Pituitary Dysfunction comment
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Hirsutism
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Hirsutism comment
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PCOS-
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PCOS comment
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Vitamin B12 Defic
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Vit B12 Defic comment
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Other-
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Other comment
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OSA
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OSA Other Comment
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Onset/Timing
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Onset Comment
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Quality, Description
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Quality/Descripton Comment
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Severity
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Severity
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Chronology
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Chronology comments
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Context
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Context Comment
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Modifying Factors
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Modifying Factors Comment
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Associated Symptoms
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Associated Symptoms Comments
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