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Referred by:
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PCP:
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Open writing:
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Telehealth Visit
|
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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Pre Diabetes
|
Pre Diabetes Comments
|
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Insulin Resistance/Dysmetabolic Syndrome
|
Insulin Resistance comments
|
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Hypoglycemia
|
Hypoglycemia comments
|
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Diabetes
|
Diabetes Type
• • •
|
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Diabetes comments
|
Daily Blood Glucose Monitoring:
• • •
|
|
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 %
|
Last A1c date
|
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Last Creat result
|
Last Creat date
|
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Last GFR result
|
Last GFR date
|
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ALB/CR Ratio
|
ALB/CR Ratio Date Done
|
|
Thyroid
|
New Multiple Select
• • •
|
|
Thyroid comments
|
|
|
Last TSH was
|
Last TSH date
|
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Last Free T4 was
|
Last Free T4 date
|
|
Last Free T3 was
|
Last Free T3 date
|
|
Osteoporosis/osteopenia
|
Osteoporosis comments
|
|
Hyperlipidemia/Dyslipidemia
|
Hyperlipidemia comments
|
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Hypogonadism
|
Hypogonadism comments
|
|
Hypertension
|
Hypertension comments
|
|
Hypotension
|
Hypotension comments
|
|
Vitamin D Deficiency
|
Vit D Defic comments
|
|
Last Vit D result
|
Last Vitamin D date
|
|
Adrenal Insufficiency
|
Primary or Secondary A.I
• • •
|
|
Adrenal Insuff comments
|
Adrenal Insuff Blood Pressure supine
/
|
|
|
Adrenal Insuff Blood Pressure standing
/
|
|
Cushing's Syndrome
|
Cushing's Syndrome comments
|
|
Pheochromocytoma
|
Pheochromocytoma comments
|
|
Diabetes Insipidus
|
Diabetes Insipidus comments
|
|
Hyperparathyroid
|
Hyperparathyroid comments
|
|
Hypercalcemia
|
Hypercalcemia comments
|
|
Obesity
|
Obesity comments
|
|
Pituitary Dysfunction
|
Pituitary Dysfunction comment
|
|
Hirsutism
|
Hirsutism comment
|
|
PCOS-
|
PCOS comment
|
|
Vitamin B12 Defic
|
Vit B12 Defic comment
|
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Other-
|
Other comment
|
|
OSA
|
OSA Other Comment
|
|
Onset/Timing
|
Onset Comment
|
|
Quality, Description
|
Quality/Descripton Comment
|
|
Severity
|
Severity
|
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Chronology
|
Chronology comments
|
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Context
|
Context Comment
|
|
Modifying Factors
|
Modifying Factors Comment
|
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Associated Symptoms
|
Associated Symptoms Comments
|
