Pre-Op Diabetes Assessment Form
Patient Name:
Medical Record Number:
Date of Birth:
Date of Assessment:
Type of Diabetes:
Type 1
Type 2
Other
Duration of Diabetes (years):
Current HbA1c (%):
Current Diabetes Medications:
Insulin Use:
Yes
No
Regimen Details (if applicable):
Complications (Check all that apply):
Retinopathy
Nephropathy
Neuropathy
Cardiovascular Disease
Other
If other, specify:
Recent Hypoglycemia Episodes:
Yes
No
Details:
Blood Glucose Monitoring:
Method:
CGM
Finger Stick
Other
Frequency (per day):
Pre-Op Instructions Given:
Additional Notes: