progress notes

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PROGRESS NOTES
NAME: ________________________________________________
DATE OF BIRTH: ________________________________________
DATE
DIABETES PROGRESS NOTE
MET WITH__________________________________________
SUBJECTIVE
Change in appetite?
What blood glucose monitor do you use?
How often do you check your blood sugar?
What is your blood sugar goal?
Are you following a specific diet?
Have you noticed any changes in your eye sight?
How often do you exercise?
Do you have sores that don’t heal?
Do you have a rash or itching?
Do you check your feet?
Do you have numbness or tingling in your feet?
How does being a diabetic make you feel?
When was your last eye exam?
Other:
Continued other side…
PROGRESS NOTES
NAME: ________________________________________________
DATE OF BIRTH: ________________________________________
DATE
DIABETES PROGRESS NOTE (continued)
OBJECTIVE
Diet Rx:
Blood Glucose monitoring Rx:
Pertinent Labs:
Wt changes:
Pertinent Meds:
Handouts Given:
Physical exam:
ASSESSMENT
PLAN
Referrals:  Podiatrist
 Endocrinologist
 Ophthalmologist
 Diabetes Educator: Diet
 Other
SBGM
New Med
__________________________________________