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Diabetes Evaluation Patient Name DOB MRN

Review of Systems www.e-medtools.com


Chief complaint Start Time Stop Time Date
Yes No
Constitution Reset

Fatigue
Fever or chills History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Taking medications as directed Checking blood glucose at home Highest blood glucose ______________
Eyes Reset
Forgot meds on several occasions Patient’s blood glucose log reviewed Lowest blood glucose ______________
Vision changes
Exercising daily Limiting diet fat, sugar Symptoms of hypoglycemia present
New pain
Scotomas
ENT/mouth Reset

Nose bleed
Caries or abscess
Jaw pain
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Respiratory Reset

Dyspnea
Cough
Phlegm
Hemoptysis
Wheeze
Cardiovascular Reset

Chest pain Allergies and Medications


Diaphoresis
Allergy List reviewed No drug allergies No food allergies
Ankle edema
Syncope
Palpitations
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Medications reviewed Medications reconciled with Hospital or Nursing Home data

Claudication
Social History Family Medical History
Gastrointestinal Reset Risk factors Reset Asthma Pancreatitis
Nausea or vomiting Denies Yes Feels safe at home or work CHF Peripheral Art Disease
Weight changes Denies Yes Tattoos Most recent COPD Renal Dysfunction
Constipation or Denies Yes High risk sexual behavior Coronary Artery Dis Thrombotic disorder
Diarrhea Denies Yes ≥2 Falls within past 12 months Premature Onset Thyroid Disease
Abdominal pain
OR 1 Fall which resulted in injury Malignancy
Genitourinary Reset

Urinary changes
Denies Yes Ever smoker _____ # Packs X _____ # Yrs Ability to Perform Activities of Daily Living Reset
Hematuria
Dysuria
Urethral discharge
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Denies
Denies
Yes Chews tobacco
Yes Quit tobacco use Quit date _________ Eating
Able Unable

Musculoskeletal Reset Patient is unwilling to quit Bathing


Myalgias Patient willing to consider quitting Dressing
Arthralgias Patient quit, but resumed smoking Toileting
Joint swelling Patient willing to quit within 1 month Transfers
Neurologic Reset Denies Yes Patient has tried smoking cessation aids Vaccines Date of last vaccination
Headaches Nicotine replacement Influenza
Seizures Buproprion or nortriptyline Pneumococcal
Muscle weakness Nicotine receptor blockade Pertussis
Endocrinologic
Hair loss
Reset

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Denies Yes Alcohol use _____ Drinks per day week
Varicella

Polydipsia/Polyuria
Denies Yes Felt the need to cut down on drinking?
Tremors
Denies Yes Annoyed by others criticizing drinking?
Neck pain
Denies Yes Guilt associated with drinking?
Heme/Lymph Reset

Bleeding gums Denies Yes Eye opener needed?


Unusual bruising
Denies Yes Recreational drug use
Swollen nodes
Inhalational Injectable Ingestible
Skin Reset

Rashes or ulcers Denies Yes Drug dependence


Narcotics Benzodiazepines

©MB and RR 2006-2008 Revised12Nov08


Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
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Diabetes Evaluation Patient Name DOB MRN

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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 www.e-medtools.com
Hepatic dysfunction
Thyroid disease, hypo
Seizure disorder
Sleep study
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 Data
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Exam ● Checked box indicates findings are within normal limits (wnl) OR finding is present

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
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TM Pharynx
Gingivitis
Dentition
Dental caries
Nasal
Oral abscess
External ears
Mucosal bleeding
Hearing
\ \/ / I
\__ /
I \ \/ /
\ __/

Neck Exam Thyroid \ / \ / \ /


Thyromegaly Thyroid nodules Goiter V / \ V
Additional Findings
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 II I
( ) ( )
I / \ I Pedal pulses weak Pedal edema present I I I I
\ ( ) / Breasts Inspection Palpation Nipple discharge I I I I
\
\ _ /
I I
\ _/
/
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GI Abdomen No hepatosplenomegaly
Abdominal mass palpable
No hernias Rectum Guaiac negative I I
I I
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 nails
Wear 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

©MB and RR 2006-2008 Revised12Nov08


Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
www.e-medtools.com

Diabetes Evaluation Patient Name DOB MRN

Plan www.e-medtools.com
Impression
Labs Completed advance health care directives in chart HCPOA is
A1C Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
BMP This patient has had the following performed within in the past 12 months
Hemoglobin A1C Level was <7.0 >7.0
BNP
Fasting LDL <130 130-140 >140
Calcium
Dental exam Date Patient taking a daily aspirin dose
Calcitonin
Dilated eye exam Date Patient taking an ACE-I or ARB
Cardiac enzymes Foot exam documented Date Patient taking a “statin”
CBC Blood pressure checked today <130/80
Insulin level www.e-medtools.com
Influenza vaccine current for this flu season
LDL and HDL Pneumococcal vaccine current (once prior to age 65 AND once after age 65)
LFTs
PTH
Triglyceride level
Troponin
TSH
Urinalysis
Microalbumin
Other
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Auto-antibodies
Islet cell
insulin
GAD65
IA-2
IA-2β
Cultures
Blood
Sputum
Urine
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Radiographs
Cardiac Stress Testing
ECHO
PFTs
Pneumococcal vaccine
Influenza vaccine
Other www.e-medtools.com
Follow Up
C-FNP or PA-C Signature
This clinic
Podiatry I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above
and I agree with the assessment and plan as outlined.
Ophthalmology
Endocrinology Physician Signature
Cardiology cc
Other

©MB and RR 2006-2008 Revised12Nov08


Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services