Endocrinology Diabetic Assessment
Patient Name
Date of Birth
Medical Record Number
Date of Assessment
Assessor
History
Diabetes Type
Type 1
Type 2
Other
Date of Diagnosis
Relevant Medical History
Family History
Current Medications
Allergies
Symptoms
Current Symptoms
History of Hypoglycemia
Diabetes Complications
Physical Examination
Height (cm)
Weight (kg)
BMI
Blood Pressure (mmHg)
Other Findings
Laboratory Results
HbA1c (%)
Fasting Blood Glucose (mg/dL)
Postprandial Blood Glucose (mg/dL)
Renal Function
Lipid Profile
Other Results
Assessment and Plan
Assessment
Plan
Patient Education / Advice
Follow-up