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Since the last visit the patientB/P:has experienced: (circle positive complaints) Pulse: No problems Difficulty controlling blood sugars Visual changes Pain/parasthesias in feet Sores on feet Frequent urination Other: Home blood glucose measurements: average ______, highest ______, lowest ______ Current medications: Medication compliance: Current diet and compliance: Coronary artery disease risk factors: personal Hx of CAD family HX of CAD dyslipidemia tobacco use obesity male Date of last ophthalmology exam:__________. Date of last 24 hr urine protein:__________ Other problems: OBJECTIVE: Weight ______, Height ______, B/P ______ Fundi: Heart: Skin: Feet: warm cool lesions present pulses sensation Other: ASSESSMENT: PLAN: HgbA1C ordered 24 hr urine protein ordered refer to ophthalmology counseled re: home blood sugar monitoring counseled re: smoking cessation refer to diabetic education classes refer to nutritionistResp: Sores on feet Frequent urination Other: Temp:Home blood glucose measurements: average ______, highest ______, lowest ______Ht:Medication compliance:Wt:Current diet and compliance:Age:Tobacco: YES NODate of last dilated fundus exam (DFE): __________LMP:Date of last 24 hr urine microalbumin: __________Last Pap:Other problems:Tetanus:Allergies:OBJECTIVE:Heart:Meds:Skin:Feet: warm cool lesions present pulses: _______ sensation: ________Other:Tech:PATIENT’S IDENTIFICATION (Use this space for Mechanical Imprint)RECORDS MAINTAINED AT:PATIENT’S NAME ( Last, First, Middle initial )SEX RELATIONSHIP TO SPONSOR: STATUSRANK/GRADESPONSOR’S NAME ORGANIZATIONDEPART./SERVICE SSN/IDENTIFICATION NO.DATE OF BIRTH62nd MDG DIABETES F/U OVERPRINT CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM 600 (EF) DATESYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) ASSESSMENT:PLAN: _____ HgbA1C ordered _____ 24 hr microalbumin ordered _____ Refer to ophthalmology _____ Counseled re: home blood sugar monitoring _____ Counseled re: smoking cessation _____ Refer to diabetic education classes _____ Refer to nutritionistMedications ordered:Lab studies ordered:Other:Follow-up in: ___________PREVENTIONS COUNSELING: STANDARD FORM 600 BACK (REV. 5-84) (EF-V1) 345p‚ƒ¾¿ÅÝÞäBCDIwxy€N O P V ƒ „ … ‹ æ ç è ì $ % & + , - 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