Medical history -
Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) -
Eating patterns, nutritional status, and weight history; growth and development in children and adolescents -
Diabetes education history -
Review of previous treatment regimens and response to therapy (A1C records) -
Current treatment of diabetes, including medications, meal plan, physical activity patterns, and results of glucose monitoring and patient's use of data -
DKA frequency, severity, and cause -
Hypoglycemic episodes -
History of diabetes-related complications -
Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) -
Macrovascular: CHD, cerebrovascular disease, PAD -
Other: psychosocial problems,* dental disease*
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Physical examination -
Height, weight, BMI -
Blood pressure determination, including orthostatic measurements when indicated -
Fundoscopic examination* -
Thyroid palpation -
Skin examination (for acanthosis nigricans and insulin injection sites) -
Comprehensive foot examination: -
Inspection -
Palpation of dorsalis pedis and posterior tibial pulses -
Presence/absence of patellar and Achilles reflexes -
Determination of proprioception, vibration, and monofilament sensation
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Laboratory evaluation |
If not performed/available within past year: -
Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides -
Liver function tests -
Test for urine albumin excretion with spot urine albumin-to-creatinine ratio -
Serum creatinine and calculated GFR -
Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia or women over age 50
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Referrals -
Annual dilated eye exam -
Family planning for women of reproductive age -
Registered dietitian for MNT -
Diabetes self-management education -
Dental examination -
Mental health professional, if needed
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