Diabetes Outpatient Review Form
Patient Name
Date of Birth
Date of Visit
Clinic/Physician Name
Type of Diabetes
Type 1
Type 2
Gestational
Other
Duration (years)
Current Medications
Recent Blood Glucose / HbA1c
Blood Pressure (mmHg)
Weight (kg)
BMI
Symptoms/Concerns
Physical Examination Notes
Foot Examination
Relevant Lab Results
Assessment / Impression
Plan & Follow-up
Additional Notes