Patient First Name:
Patient Last Name:
New Diagnosis of Gestational
Previous History of Gestational
Fluctuating Blood Glucose
Change in Treatment Plan
Ineffective Home Maintenance
Insulin Administration Instruction
Reaction to having diabetes:
Present health status:
Other medical problems:
Previous diabetes education:
Relevant socioeconomic factors:
The physician has explained any/all potential risks to me and my baby related to diabetes and pregnancy.
Last 6 months?
Last eye exam:
Last dental exam:
Medication(s) for diabetes: Refer to chart
Blood glucose today:
Number of hours post prandial:
Most recent glycohemoglobin:
NURSING PROBLEMS/IMPRESSIONS/HEALTH GOALS EDUCABILITY
Knowledge pre-test score:
Barriers to learning:
Pre pregnant weight:
Estimated calories needed to maintain current weight BEE x AF ( ) =
By MD By RD
24 HOUR FOOD RECALL
ETOH None or Type:
DIETARY PROBLEMS/IMPRESSIONS/ HEALTH GOALS
NEW MEAL PLAN Should promote
See attached plan – Calories
3 meals, 3 snacks or
Meal Plan Comments
See General Nutrition Guidelines
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.
Treatment for Low Blood Sugars: See attached Guidelines
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.
Educator First Name:
Educator Last Name:
Contact Phone Number :
CDE Signature and Credentials*:
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.
Diabetes Educator Signature
* = Input is required