Diabetes Complications Assessment Form
Assess diabetes-related complication symptoms, recent measurements, and current management. Do not enter sensitive information beyond what is asked.
Diabetes History
Diabetes type or diagnosis context
*
Years since diagnosis
*
Recent Measurements
Recent blood sugar pattern (average mg/dL)
*
Recent A1C (%)
Current Management
Current diabetes management approach
*
Diet and lifestyle only
Oral medication
Insulin
Oral medication and insulin
Unsure
Self-management supports or warning signs monitored
Foot checks
Eye exams
Blood pressure monitoring
Glucose logs
Medication adherence
None of the above
Follow-up Notes
Additional concerns, observations, or questions
Request follow-up review of assessment results
*
Yes
No
Submit Assessment
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