DIABETES EDUCATION RECORD

DIABETES CARE CENTER



Date:


Patient First Name:

Patient Last Name:

Phone (Home):

Phone (Work):

Family contact:

Cell Number:

Address:

Referring physician:

Age:

Occupation:

Accompanied by:

Gestational:

Pre-gestational:

Type 1

Type 2

GTT Results:

 

 

 

 

Parity:

Full Term

Pre-Term

Abortions

Live Births

Gravida :

EDC:

IUP (weeks):

Medication Allergies:

Reason For Visit

Pre-Gestational

New Diagnosis of Gestational

Previous History of Gestational

Fluctuating Blood Glucose

Recurrent Hypoglycemia

Change in Treatment Plan

Ineffective Home Maintenance

Insulin Administration Instruction


SUBJECTIVE


Reaction to having diabetes:

Present health status:

Good

Fair

Poor

Other medical problems:

Stress:

Yes

No

Stressors:

Previous diabetes education:

Yes

No

Where:

When:

Support system:

Relevant socioeconomic factors:

Exercise/activity routine:

Any Restrictions:

Yes

No

Specify:

The physician has explained any/all potential risks to me and my baby related to diabetes and pregnancy.

Yes

No


PREGESTATIONAL ONLY


Hypoglycemia:

Last 6 months?

Yes

No

Symptoms?

Yes

No

Food related?

Yes

No

Exercise Related?

Yes

No

Hospitalized?

Yes

No

Hyperglycemia:

Last 6 months?

Yes

No

Hospitalized?

Yes

No

Circumstances:


Glucose Monitoring:

Yes

No

Meter Type:

Frequency:

Records?

Yes

No

Ketone testing:

Yes

No

Last eye exam:

Last dental exam:

Medication allergies:

Medication(s) for diabetes: Refer to chart

or


OBJECTIVE


Blood glucose today:

Fasting:

Yes

No

Number of hours post prandial:

Most recent glycohemoglobin:

None


NURSING PROBLEMS/IMPRESSIONS/HEALTH GOALS EDUCABILITY


Receptive:

Yes

No

Knowledge pre-test score:

Motor skills:

Able

Needs Assistance

Not Able

Mental status:

Alert

Oriented

Confused

Needs Repetition

Barriers to learning:

Physical

Financial

Family/Social

Emotional

Vision Difficulties

Hearing Difficulties

Reading Problems

Impression:

Plan:


NUTRITION


Height:

Weight:

Pre pregnant weight:

Recent Change:

Yes

No

IBW

Goal Wt

Estimated calories needed to maintain current weight BEE x AF ( ) =

Kcal

Diet order

By MD By RD

Other restrictions/diets/problem:

Pertinent labs:


24 HOUR FOOD RECALL


Breakfast Time:

Lunch Time:

Dinner Time:

Snacks:

Snacks:

Snacks:

Food Likes:

Dislikes:

Vitamins/ Supplements:

Food Allergies:

ETOH None or Type:

Amount:

DIETARY PROBLEMS/IMPRESSIONS/ HEALTH GOALS

NEW MEAL PLAN Should promote

weight maintenance

weight gain

Other:


MEAL PLAN

CALORIES:

MEALS:

SNACKS:


EXCHANGE

BREAKFAST

LUNCH

DINNER

AM

PM

HS

MILK

VEG

FRUIT

BREAD

MEAT

FAT


GRAM TOTAL

PERCENTAGE


DIABETES EDUCATION


SELF CARE INSTRUCTIONS I – PREGNANCY


Patient First Name:

Patient Last Name:

Date:

Meal Plan

See attached plan – Calories

3 meals, 3 snacks or

Meal Plan Comments

See General Nutrition Guidelines

Activity/Exercise

20-30 minutes per day, non-ballistic activity, see General Exercise Guidelines – do not exercise if your MD has restricted your activity

Blood Sugar Testing

Pre-breakfast and 2 hours after the start of each meal. Keep a record on the attached form.

MEDICATION TYPE

Pre Breakfast

Pre Lunch

Pre Dinner

HS

Treatment for Low Blood Sugars: See attached Guidelines

Other Instructions

Target blood sugars: Fasting 60-90 and post meals less than 120. Urine ketones should be negative. Call the office during business hours, 305-669-9521 & speak with Vanexa, if values are outside of ranges for 3 days.


Patient First Name:

Patient Last Name:

Patient Signature

Educator First Name:

Educator Last Name:

Contact Phone Number :

Educator First Name:

Educator Last Name:

Contact Phone Number :

CDE Signature and Credentials*:

Date

CDE Signature and Credentials*:

Date


Anthony R. Lai, M.D., Jorge L. Gomez, M.D.

I have been informed of the importance of monitoring my sugar levels and the baby's health as recommended by SFPM.

I agree to report my blood sugars every Sunday night.

I agree to attend all my appointments for fetal monitoring at SFPM.

I understand that failure to follow any of the above recommendations will result in the immediate discharge from the diabetic program.

Patient Signature

Date

Diabetes Educator Signature

Date

* = Input is required