SGLT2 Inhibitor Initiation Checklist Form
Complete this form to document the key checks, medication details, and follow-up plan before starting an SGLT2 inhibitor.
Patient and Medication Basics
Patient name
*
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prescriber name
*
Indication / reason for SGLT2 inhibitor initiation
*
Selected SGLT2 inhibitor
*
Please Select
Empagliflozin
Dapagliflozin
Canagliflozin
Ertugliflozin
Other
Clinical Screening Checklist
Renal function reviewed
*
Yes
Volume status assessed
*
Yes
Current diabetes medications reviewed
*
Yes
History of recurrent genital yeast infections reviewed
Yes
History of prior ketoacidosis reviewed
*
Yes
Patient counseled on sick-day guidance
*
Yes
Start Plan and Follow-Up
Planned Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Baseline Lab Review Status
*
Please Select
Reviewed
Pending
Unavailable
Follow-Up Timeframe After Initiation
*
Please Select
1 week
2 weeks
4 weeks
6 weeks
8 weeks
Other
Clinician Notes / Special Instructions
Submit
Should be Empty: