Diabetic Home Health Evaluation Checklist
Patient Information
Name
Date
Address
Contact Number
Vital Signs
Blood Glucose Level (mg/dL)
Blood Pressure (mm Hg)
Weight (kg)
Temperature (°C)
Pulse (bpm)
Checklist
Medication reviewed and administered
Insulin storage and administration checked
Blood glucose monitoring reviewed
Dietary habits assessed
Physical activity discussed
Foot inspection completed
Skin condition assessed
Signs of hypo/hyperglycemia assessed
Emergency plan discussed
Patient/caregiver education provided
Additional Notes
Signature
Evaluator Name
Signature
Date