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Diabetes Evaluation
Patient Name DOB MRN
©MB and RR 2006-2008 Revised12Nov08
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Review of Systems Chief complaint
Start Time Stop Time Date
History of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Taking medications as directed
Checking blood glucose at home Highest blood glucose ______________
Forgot meds on several occasions
Patient’s blood glucose log reviewed Lowest blood glucose ______________
Exercising daily
Limiting diet fat, sugar
Symptoms of hypoglycemia present
Allergies and Medications
Yes NoConstitution
Fatigue
Fever or chills
Appetite changes
Eyes
Vision changes
New painScotomas
ENT/mouth
Nose bleedCaries or abscessJaw pain
Respiratory
DyspneaCoughPhlegmHemoptysisWheeze
Cardiovascular
Chest painDiaphoresisAnkle edemaSyncopePalpitationsClaudication
Gastrointestinal
Nausea or vomitingWeight changesConstipation orDiarrheaAbdominal pain
Genitourinary
Urinary changesHematuriaDysuriaUrethral discharge
Musculoskeletal
MyalgiasArthralgiasJoint swelling
Neurologic
HeadachesSeizuresMuscle weakness
Endocrinologic
Hair lossPolydipsia/PolyuriaTremorsNeck pain
Heme/Lymph
Bleeding gumsUnusual bruisingSwollen nodes
Skin
Rashes or ulcers
Allergy List reviewed
No drug allergies
No food allergies
Medications reviewed
Medications reconciled with Hospital or Nursing Home data
Social History Family Medical History
Risk factors
Asthma
Pancreatitis
Denies
Yes
Feels safe at home or work
CHF
Peripheral Art Disease
Denies
Yes
Tattoos
Most recent
COPD
Renal Dysfunction
Denies
Yes
High risk sexual behavior
Coronary Artery Dis
Thrombotic disorder
Denies
Yes
≥
2
Falls within past 12 months
Premature Onset
Thyroid Disease
OR
1 Fall which resulted in injury
Malignancy
Denies
Yes
Ever smoker
_____ # Packs X _____ # Yrs
Ability to Perform Activities of Daily Living
Denies
Yes
Chews tobacco
Able Unable
Denies
Yes
Quit tobacco use
Quit date _________ Eating
Patient is unwilling to quit Bathing
Patient willing to consider quitting Dressing
Patient quit, but resumed smoking Toileting
Patient willing to quit within 1 month Transfers
Denies
Yes
Patient has tried smoking cessation aids Vaccines
Date of last vaccination
Nicotine replacement
Influenza
Buproprion or nortriptyline
Pneumococcal
Nicotine receptor blockade
Pertussis
Varicella
Denies
Yes
Alcohol use
_____ Drinks per
day
week
Denies
Yes Felt the need to cut down on drinking?
Denies
Yes Annoyed by others criticizing drinking?
Denies
Yes Guilt associated with drinking?
Denies
Yes Eye opener needed?
Denies
Yes
Recreational drug use
Inhalational
Injectable
Ingestible
Denies
Yes
Drug dependence
Narcotics
Benzodiazepines
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Diabetes Evaluation
Patient Name DOB MRN
©MB and RR 2006-2008 Revised12Nov08
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Past Medical and Surgical History
Asthma
Hypertension
Chemotherapy
Surgeries
Adrenal dysfunction
Inflammatory Bowel Disease
Colonoscopy
CABG
Arthritis
Irritable Bowel Syndrome
ECHO/Stress test
Splenectomy
Cerebral Artery Dis
Myocardial Infarction
Immunosuppressive therapy
Organ transplant
CHF
Neuromuscular weakness
Mammogram
Other
COPD
Pancreatitis
Organ failure
Coronary Artery Dis
Peripheral Artery Disease
PFTs
Cystic Fibrosis
Renal dysfunction
Pap Smear
Diabetes
1
2
Thrombotic disease
Prior intubations
GERD
Thyroid disease,
hyper
Radiation exposure
Gout
Thyroid disease,
hypo
Sleep study
Hepatic dysfunction
Seizure disorder
Steroid use, chronic
HIV/AIDS
Sleep Apnea
CPAP
BiPAP
Strokes
Malignancy
If 2 or more, consider Multiple Endocrine Neoplasia (MEN1)
Entero-Pancreatic
Parathyroid
Pituitary
Consider MEN2
Thyroid
Pheochromocytoma
Cutaneous lichen amyloidosis
Parathyroid hyperplasia
Acanthosis nigricans
Adrenal
Breast
Bone
Colon
Hepatic
Lung
Lymphoma
Prostate
Testicular
Diagnostic DataExam
Checked box indicates findings are within normal limits (wnl) OR finding is present
\____/ / \ ____ / ____ / ____ / \ \ \
Additional Findings
()
()
()
()
() ()
()
()
()
()
( ) ( )I
/ \ I \ ( ) / \ I I / \ _ / \ _ /
Ht
in
cm
Wt
lb
kg
BMI Temp P
rate
Regular
Irregular
BP
Sitting
Lying
Standing
R Sats %General
Alert
Cachectic
Obese
Hygiene appropriate
Eye
Conjunctivae clear
Pupils
Discs are within normal limits _
Conjunctival erythema
Xanthelasma
Cotton-wool spots
A-V nicking / \
Retinal hemorrhage
Dilated or tortuous vessels
Neovascularization \ /
Macular edema
Vascular narrowing _ _I I _ _
ENT
TM
Pharynx
Dentition
Nasal
External ears
Hearing \ _ _ / \ _ _ /
Gingivitis
Dental caries
Oral abscess
Mucosal bleeding
\ \/ / I I \ \/ /
Neck
Exam
Thyroid
\ / \ / \ /
Thyromegaly
Thyroid nodules
Goiter V
/ \
V
Resp
Auscultation wnl
Normal effort
Percussion wnl
Palpation wnl
I I
CV
Auscultation
Palpation
Edema
Carotid
Aorta
I I I
Femoral pulses palpable and symmetric
Pedal pulses palpable and symmetric
I I I I
Pedal pulses weak
Pedal edema present
I I I I
Breasts
Inspection
Palpation
Nipple discharge I I I I
GI
Abdomen
No hepatosplenomegaly
No hernias
Rectum
Guaiac negative
I I I I
Abdominal mass palpable I I I I
Lymph
Neck
Axilla
Groin
Other
I I I I
Musc
Gait
Digit
Inspection
ROM
Stability
Strength < l l >
Atrophy present
Location
Skin
No clubbing
No cyanosis
No ulcers
No callouses
No ingrown nailsWear pattern on shoes
Normal
Abnormal
Callous
Onychomycosis
Ulcer present
Location
Lichenification present
Location
Hyperpigmentation present
Location
Neuro
CN
DTR
Sensation intact
Vibratory sense intact
Decreased sensation
Vibratory sense decreased
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