Diabetes Post-Discharge Follow-up Form
Patient Name
Medical Record Number
Date of Birth
Follow-up Date
Current Medications
List diabetes medications and dosages
Blood Glucose Monitoring
Recent blood glucose readings
Any hypoglycemic events?
Yes
No
Any hyperglycemic events?
Yes
No
Education & Self-Management
Education provided (diet, medication, monitoring, etc.)
Barriers to management
Other Instructions or Notes
Additional notes
Next Appointment Date