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Diabetes Flow Sheet: Baylor/Agape Outreach

Patient Name:

Instructions: Complete flow sheet. Answers indicating presence of problem should be circled, further explored, and if significant, SOAPed. Patient involvement in care is critical to successful treatment of diabetes. Focus on this issue in every encounter. Update medication list with complete information (include prescriber's name) and determine if patient is compliant.

Parameter (initial by date)	Date/	Date/	Date/	Date/
Medications - Compliant? List below	.	.	.	.
General	.	.	.	.
Pain (Chest, other)	.	.	.	.
Appetite	.	.	.	.
Sleep	.	.	.	.
Fatigue/tired	.	.	.	.
Fever/chills	.	.	.	.
Weight changes	.	.	.	.
Specific to Diabetes
Polydipsia	.	.	.	.
Polyphagia	.	.	.	.
Polyuria	.	.	.	.
Weakness/fatigue	.	.	.	.
Blurred vision	.	.	.	.
S/S UTI/GU pruritis	.	.	.	.
Peripheral neuropathy (sites)	.	.	.	.
Nocturia (# times/night)	.	.	.	.
Self-Management
Blood glucose checks/week (recorded)	.	.	.	.
BP checks/week recorded	.	.	.	.
Weights/week recorded	.	.	.	.
Verbalizes specific diet	.	.	.	.
Identifies foods +/- in diet	.	.	.	.
Exercise: days/week & minutes/day	.	.	.	.
Verbalizes foot care	.	.	.	.
Lipids, HgBA1C last drawn	.	.	.	.
DFS today (fasting?)	.	.	.	.
BP today	.	.	.	.
AP/Resp today	.	.	.	.
Inspect feet - lesions?	.	...	.	.

List medications (note if using back of sheet, include dose, frequency, doctor/NP)