Medical historyAge and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) Eating patterns, physical activity habits, 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 and medication adherence, meal plan, physical activity patterns, and readiness for behavior change 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 examinationHeight, 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 |
ReferralsEye care professional for annual dilated eye exam Family planning for women of reproductive age Registered dietitian for MNT DMSE Dentist for comprehensive periodontal examination Mental health professional, if needed
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