TARGET CLIENT LIST FOR TYPE II DIABETES MELLITUS

BMI

Physical
Smoker

Alcohol
Current

Activity
Type of Client

Drinker
Ht (In)

Binge
Date of

(New/Old)
Overweight: 23.0-
No. Registration Name Address Sex Date of birth Age Wt (kg)
24.9 kg/m2 Normal:
(MM/DD/YYYY) (Family Name, First Name, Middle Initial) (M/F) (MM/DD/YYYY) 20-39 y.o. 40-59 y.o. 60 y.o. & Y-Yes Y-Yes Y-Yes Waist 18.5 - 22.9 kg/m2
above Circumferenc Obese: ≥ 25 kg/m2
N-No N-No N-No
e (cm)

8
 TARGET CLIENT LIST FOR TYPE II DIABETES MELLITUS
FOLLOW-UP VISITS (Every month until controlled state; thereafter, patients should be monitored at least every six months)
Was the
patient also
Prescribed Medication (Sub-row 1: Service Date/ Sub-row 2: Next Visit/ Sub-row 3: Result/ Sub-row 4: Medication given) Remarks diagnosed
Positive (+): FBG ≥ 126mg/dL or RBS ≥ 200mg/dL; Negative (-): FBG < 126mg/dL or RBS < 200mg/dL as having
HPN? (Y/N)
Jan Feb Mar Apr May June Jul Aug Sept Oct Nov Dec