Diabetes Self-Management History Update Form
Date
Patient Name
Date of Birth
Current Diabetes Management
Date of Diabetes Diagnosis
Type of Diabetes
Type 1
Type 2
Gestational
Other
Current Medications (type, dose, frequency)
Self-Monitoring of Blood Glucose
Last HbA1c (%)
Date of Last HbA1c
Lifestyle and Self-Management
Diet Plan
Physical Activity/Exercise Routine
Recent Complications or Hypo/Hyperglycemic Events
Support Systems (family, friends, groups)
Education and Follow-Up
Diabetes Education Received
Self-Management Goals
Questions or Concerns