BASELINE RISK ASSESSMENT
Hypertension
Dyslipidemia
Peripheral artery disease
Kidney disease
Retinopathy
Erectile dysfunction
Coronary heart disease
Stroke/TIA
Foot problems
Alcohol consumption (___ drinks/week)
Mental health diagnosis: ___________________________
Smoking:
never
current
past (_____ pack/day x ______ years)
Name: ____________________________________
D.O.B.: ___________________________________
Current drug allergies: ______________________
__________________________
Type of DM: ___ Type 1 ___ Type 2
Age at diagnosis: ________
Date:
Height: ________________________
Weight/BMI:
Waist circumference:
Glycemic Control
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TEST TO USE
Glucose-lowering medications:
Record medication changes
Fasting glucose level 4 to 7 (mmol/L)
Fasting plasma glucose (mmol/L)
Simultaneous fasting venous/capillary blood glucose (should be within 20%)
at least annually
Every 3 to 6 months: target < 7%
A1C:
Mean glucose (mmol/L):
6%
7%
> 8%
7
8.6
10.2
A1C (%)
Hypertension
Review self-monitoring of blood glucose records*
Targets: preprandial 4 to 7 mmol/L; 2 hour postprandial 5 to 10 mmol/L
(5 to 8 mmol/L if not achieving A1C target)
Heart
3 TO 6 M O N T H S
DIRECTIVE
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Antihypertensives:
Record medication changes
Goal: < 130/80 mm Hg
Blood pressure (mm Hg)
[
[
Resting ECG at diagnosis
(baseline)
Every 2 years (if high risk)
] Not high CV risk
] High CV risk†
Is patient taking ASA?
Lipids
Lipid-lowering medications:
Record medication changes
Annual fasting
lipid profile
Targets for those at
high risk of CVD
Total Chol (mmol/L)
(< 2)
LDL-C (mmol/L)
(Not at high CV
risk: target LDL-C
<3.5, TC/HDL < 5)
HDL (mmol/L)
TG (mmol/L)
ACR target (M: < 2, F: < 2.8)
Dilated eye exam
Type 1: Annually > 15 years of age and
5-year history of DM
Type 2: At diagnosis, then as indicated,
at least every 2 years
Date of last ophthalmologist/
optometrist appointment
Check feet for lesions and sensation,
and note findings
Sensory testing:
10 g monofilament or tuning fork
(great toe)
Neuropathy
Renal
Ratio (Total Chol/HDL)
Screen for Nephropathy
Type 1: Annual > 15 years of age and
5-year history of DM
Type 2: At diagnosis, then annually
Eyes
(< 4)
Immunization
A N N U A L O R A S I N D I C AT E D
Is patient taking an ACEI or ARB?
Annual influenza:
Serum creatinine (µmol/L)
eGFR (mL/min)
Record date of shot
(Pneumococcus date: _______________________________________)
*For more information, see the Optimal Therapy Recommendations for the Prescribing and Use of Blood Glucose Test Strips from the Canadian Agency for Drugs and Technologies in Health (www.cadth.ca/smbg).
†Definition: Men > 45 years, women > 50 years OR diabetes duration > 15 years and age > 30 years; OR macro- or micro-vascular disease; OR multiple risk factors (especially family history of premature heart
disease or stroke); OR one extreme risk factor (LDL-C > 5.0, systolic BP > 180); Source: Is this patient at high risk for a vascular event? [Internet]. Toronto: Canadian Diabetes Association; 2009. [cited 2010 Jan 8].
Available from: http://www.diabetes.ca/documents/about-diabetes/Clinical_Tool_FINAL.pdf
ACR = albumin-creatinine ratio.
Disclaimer: This information is not a substitute for professional medical advice or care. CADTH is not liable for any damages resulting from the use or misuse of information contained in or implied by the
information in this document.
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