Diabetes CARE Checklist
Name: ________________________________________________________________
The goal of the Diabetes CARE program is to help you manage your diabetes and stay healthy. Use this checklist to record the dates of each screening. You will
need to submit this Checklist to the PCS Diabetes CARE Coordinator* along with your course completion certificate once a year as proof of your commitment and in
order to continue participation in the program. List the providers name only. Do NOT list your screening results as this is your private medical information.
A1c
Average
blood
glucose
(Goal: less
than 7%)
Blood
Pressure
Urine
Proteins
(Goal: less
than
130/80)
(microalbumin)
Cholesterol
Other Exams
LDL
HDL
Triglycerides
Eye Exam
Foot Exam*
(Goal: less
than 100)
(Goal;
Men= >40mg/dl
Women=
>50mg/dl)
(Goal: less
than150mg/dl)
(Dilated eye
exam)
(must be done by
your Primary Care
Physician or
Endocrinologist)
Diabetes
Education
Morton
Plant or
St. A’s
Enroll in Humana’s
Disease
Management
Program by calling
888-444-9973
Date
Provider
Name or
location
Listed goals are the recommended values for people with diabetes. Goals and recommendations are based on American Diabetes Association 2008 guidelines for a
nonpregnant adult.
Glycosylated Hemoglobin or Hemoglobin A1c: This blood test measures the
average blood glucose level over the past 2 to 3 months. The goal is less than 7%. If
you are not within goal, please talk to your physician.
Urine Microalbumin: This simple urine test screens for microscopic amounts of
albumin (protein) in the urine that may point to early signs of kidney disease. If test
results are positive, please talk to your physician.
Dilated Retinal Exam: Diabetes is a leading cause of blindness due to its effects on
the retina, the back portion of the eye. An annual dilated eye exam by an
ophthalmologist or optometrist improves the chance of early detection and treatment.
(This exam is different than a routine eye exam for eyeglasses or contact lenses
because the eye doctor uses special equipment and procedures to examine the blood
vessels in your eyes.)
*Important! Submit this Checklist to:
OFFICE # 727-588-6137 FAX # 727-588-6182
The exam does not require a referral when you visit a participating EyeMed or Aetna provider.
Please ask the provider to send test results to your physician.
LDL cholesterol screening: This annual blood test evaluates the level of low-density
lipoprotein (LDL), the so-called “bad” cholesterol in the blood. High LDL levels can lead to heart
disease. Using test results, your doctor can monitor your cholesterol and prescribe medication or
lifestyle changes as necessary. If you are not within goal, please talk to your physician.
*Foot exam: People with diabetes sometimes experience circulatory problems, particularly in
their extremities. Minor ulcers in the feet can develop and grow into significant medical problems
requiring surgery. Having your feet examined by your doctor during all of your routine office
visits can prevent serious problems. Talk with your physician any time you have a sore on
your foot.
Heather Keegan, Humana Patient Advocate/Diabetes CARE Program Coordinator
Pinellas County Schools Risk Management and Insurance Department
301 4th St. SW, Largo, FL 33770
Pinellas County Schools
Diabetes CARE Program
March 2008, revised July 2013