Complications Risk Assessment Report and Recommendations
Client Name:
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First Name
Last Name
Date of Birth:
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Day
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Month
Year
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E-mail
Screening Date:
*
-
Day
-
Month
Year
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Clincian
Type of Assessment:
Please Select
1. Baseline Diabetes Assessment
2. Complications Risk Assessment
Assessment Findings
Diabetes
Please Select
Yes
No
Pre-Diabetes:
Please Select
Yes
No
Neuropad Result
Please Select
Normal
Abnormal
Mixed
HbA1C Results
Reported Co-morbidities
YES
No
Not Sure
Heart Disease
Depression
Anxiety
Sleep Apnoea
COPD
Neuropathy
Peripheral vascular Disease
Osteoarthritis
Psoriatic Arthritis
Rheumatoid Arthritis
Kidney disease
Eye Disease
Kidney Disease
Comments
Foot Check
Risk Level for Diabetes Foot Complications
Comments
Workplace
Describe:
Comments:
Diet
Comments and Recommendations::
Exercise
Comments and Recommendations:
Footwear
Comments and Recommendations
Sleep/Stress
Comments and Recommendations::
Willingness to Engage in Health Improving Lifestyle Modifications
5
4
3
2
1
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits,exercise)
Practice a relaxation rechnique
Engage in regular physical exercise/physical activity
Have periodic lab teats to assess your progress
Comments:
Risk Discussion
Reccomendations
Helpful References
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