Specifications

82 III For Providers
The EyePACS Handbook: Tools for Program Success
Diabetes Visit Checklist (Example)
Date:
PCP:
AGE:________
RACE: ________
SEX: ________
BP: ________ PULSE: ________ TEMP: ________ HT: ________ WT: ________
Current medications:
Laboratory tests sent:
 Hb1Ac  Micro/Alb  Chem 8
 Lipid profile  Lfts  Other
Immunizations updated:
 Pneumo  Tetanus
 Flu  Other
Retinopathy Exam:
 Done within last 12 months
(date)
 Referral to
(provider’s name)
Diabetes education referral:
Done within the last 12 months?  Yes  No
Foot exam:
(“Y” or “N” to indicate findings) Right Left
Is there a foot ulcer or history of foot ulcer?
Is there toe deformity?
Is there abnormal shape?
Are toenails thick or ingrown?
Are pulses absent?
Can patient see bottoms of his/her feet?
Is patient wearing improperly fitting shoes?
Personal health goals:
 None
 Current goal
 Handout given
___________________________________
Signature and Title