Perioperative Diabetes Assessment Form
Complete this form to review diabetes history, current treatment, recent glucose control, and perioperative management needs before surgery or a procedure.
Patient and Procedure Details
Patient Name
*
First Name
Middle Name
Last Name
Age
*
Sex at Birth
Female
Male
Intersex
Prefer not to say
Gender Identity
Woman
Man
Non-binary
Another identity
Prefer not to say
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Scheduled Surgery/Procedure Name
*
Surgical Specialty or Procedure Type
*
Please Select
General Surgery
Orthopedics
Cardiology
Neurosurgery
Gynecology
Urology
Ophthalmology
ENT
Vascular Surgery
Plastic Surgery
Other
Date and Time of Surgery/Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Anesthesiology or Pre-op Clinic Visit Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Diabetes History and Current Treatment
Diabetes Type
*
Type 1
Type 2
Gestational
Other
Year of Diagnosis
Current Diabetes Medications
Oral Agents
Insulin
GLP-1 Medication
Other
Insulin Regimen Details
Timing of Last Diabetes Medication Dose
Diabetes Technology Used
Insulin Pump
Continuous Glucose Monitor (CGM)
Neither
Other
Self-Monitors Glucose
Yes
No
Sometimes
Not Applicable
Diabetes-Related Complications or Comorbidities
Recent Glycemic Control and Monitoring
Recent HbA1c (%)
Date of HbA1c test
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Usual fasting glucose range
Recent home blood glucose readings
How often do you usually check glucose?
Please Select
Never
Less than once daily
Once daily
2–3 times daily
4 or more times daily
Continuous monitor
Other
Recent hypoglycemia or hyperglycemia
Low glucose episodes
High glucose episodes
Both low and high episodes
No recent episodes
Unsure
Perioperative glucose monitoring assessment
Very limited
1
2
3
4
5
6
7
8
9
Highly prepared
10
1 is Very limited, 10 is Highly prepared
Perioperative Status and Risk Assessment
Are you currently fasting or NPO?
*
Yes
No
Unsure
Time of last oral intake
*
Hour Minutes
AM
PM
AM/PM Option
Time of last carbohydrate intake
Hour Minutes
AM
PM
AM/PM Option
Symptoms today suggesting low or high glucose
Low glucose symptoms
High glucose symptoms
None
Unsure
Do you have a current illness or infection?
No
Yes
Unsure
Are you currently taking steroid medication?
No
Yes
Unsure
Do you have kidney or renal disease?
No
Yes
Unsure
Prior anesthesia or surgery issues related to diabetes management
Perioperative Management Plan and Acknowledgment
Planned Diabetes Medication Adjustments Before Surgery
*
Hold morning dose
Reduce basal insulin dose
Continue usual dose
Take only clear liquids with medications
Other
Day-of-Surgery Glucose Management Plan
*
Check glucose on arrival
Administer correction insulin as needed
Proceed with usual regimen
Hold diabetes medications until after procedure
Other
Need for Endocrine Consultation
*
Yes
No
Already consulted
Post-Operative Glucose Monitoring Plan
*
Please Select
Routine floor checks
Frequent bedside glucose checks
Continuous glucose monitoring if available
ICU-level monitoring
Other
Clinician Notes
Submit Assessment
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