Diabetic Patient Nursing Assessment Form
Patient Identification
Patient Name
Date of Assessment
Medical Record No.
Date of Birth
Sex
Male
Female
Other
Medical History
Type of Diabetes
Type 1
Type 2
Gestational
Other
Year Diagnosed
Other Medical Conditions
Current Medications
Vital Signs
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Blood Glucose Level
Weight
Assessment Findings
Chief Complaints
History of Present Illness
Physical Assessment
Skin Condition (ulcers, wounds, etc.)
Neuropathy Symptoms
Foot Assessment
Eye Assessment
Diet & Nutrition Habits
Activity/Exercise Patterns
Education & Self-care
Understanding of Diabetes
Medication Adherence
Barriers to Self-care
Nursing Interventions/Recommendations
Assessed by (Nurse Name)
Signature