DIP Checklist Template A. General Patient Information Checklist Template for DIP Checklist Template for DIP A. General Patient Information Name: MR #: Age / Gender: Date of Admission: Attending Physician: Date of Interview: B. Presenting Complaint(s) Polyuria Polydipsia Polyphagia Fatigue Blurred vision Weight loss Recurrent infections Wound healing issues Others: C. History of Present Illness Onset, duration & progression of symptoms: D. Systemic Review – General Weight changes: Yes No Fatigue: Yes No Fever / Night sweats: Yes No Note: Due to the document's length, this is a working template with key sections formatted in HTML. More sections can be added in the same structured format. D. Systemic Review – Cardiovascular Chest pain / Angina Palpitations Hypertension History of MI Peripheral Edema PAD symptoms D. Systemic Review – Respiratory Cough Dyspnea Wheezing / Asthma / COPD D. Systemic Review – Gastrointestinal Appetite changes Nausea / Vomiting Abdominal pain Constipation History of fatty liver Pancreatitis Diarrhea D. Systemic Review – Genitourinary Urinary frequency Nocturia Urgency Recurrent UTIs Sexual Dysfunction (ED in males) Menstrual Irregularities (in females) D. Systemic Review – Neurological Headache Dizziness Visual changes / Retinopathy Peripheral neuropathy symptoms History of stroke / seizures / TIA D. Systemic Review – Musculoskeletal Joint pain / Stiffness / Swelling Limited mobility Muscle cramps D. Systemic Review – Skin Ulcers / Non-healing wounds Infections / Fungal infections Acanthosis Nigricans Nails D. Systemic Review – Obstetric History Gravida: Abortions (miscarriages/terminations): Para: Preterm births: Term births: Mode of delivery: GDM HTN Others: Gynaecological History Menstrual history: Age at menarche: Last menstrual period: Cycle length and regularity: Duration and amount of bleeding: Infertility history: Blood Glucose Monitoring Recent blood glucose readings / home monitoring: Hypoglycemic episodes: Yes No Frequency: Severity: Compliance with medication: Yes No Insulin use: Yes No Type & dose: E. Past Medical History Type 1 DM Type 2 DM Duration (years): Hypertension Hyperlipidemia CAD Stroke/TIA CKD Neuropathy Retinopathy Foot ulcers Other comorbidities / Comments: F. Past Surgical History G. Family History Diabetes Hypertension CAD Obesity Stroke CA Others: H. Medicine History Current medications: OHA: Insulin doses: Good Compliance Poor Compliance I. Allergies None Yes Specify: J. Personal/Social History Smoking: Never Past Current Alcohol use: Never Past Current Sleep pattern: Physical activity level: Diet pattern: J. Psychosocial Screening (Checklists) GAD-7 (Generalized Anxiety Disorder) Excessive anxiety and worry (most days ≥ 6 months) Difficult to control the worry Restlessness or feeling keyed up/on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbances Causes significant distress or impairment Not due to substances or medical conditions 0–4 Minimal 5–9 Mild 10–14 Moderate 15–21 Severe PHQ-9 (Depression) Depressed mood Loss of interest or pleasure Weight/appetite changes Sleep disturbances Psychomotor agitation/retardation Fatigue/loss of energy Feelings of worthlessness/guilt Trouble concentrating Suicidal thoughts Not due to medical/substance cause 0–4 None 5–9 Mild 10–14 Moderate 15–19 Moderately Severe 20–27 Severe Disease-related Depressed Mood Loss of motivation Guilt/shame due to illness Hopelessness Avoidance of treatment Comment: 2. Physical Examination Template A. General Appearance No apparent distress Obese Cachectic Dehydrated Anxious Depressed Others: B. Vitals Temp (°C): Pulse (bpm): BP (mmHg): RR (/min): SpO₂ (%): Weight (kg): Height (cm): BMI: C. Systemic Examination 1. Cardiovascular Normal S1/S2/No murmur Murmur Edema Irregular rhythm 2. Respiratory Clear Crackles Wheeze 3. Abdominal Soft Tenderness Organomegaly Ascites 4. CNS Normal Cranial nerves (2–12) Gait abnormality Decreased sensation Cerebellar signs Reflexes: Biceps Triceps Knee Ankle 5. Foot Examination Intact skin Ulcers Fungal infection Deformity Neuropathy (monofilament test) Nail 6. Eye Examination Normal Retinopathy signs Fundoscopy notes: 3. Assessment & Diabetes Management Plan Template A. Diagnosis Type 1 DM Type 2 DM Newly Diagnosed HTN CKD Decompensated DM (e.g. DKA, HHS) Other: B. Glycemic Control Assessment Last HbA1c (%): Date: Fasting glucose (mg/dL): RBS / Postprandial (mg/dL): SMBG frequency: C. Labs & Investigations CBC HbA1c FBS/PPBS LFTs RFTs / Creatinine Lipid Profile Urine Routine / ACR TSH Vitamin D, B12, Folate Uric Acid ECG Fundoscopy ECHO X-ray Others: D. Risk Factors Obesity Sedentary lifestyle Poor diet Stress Non-compliance Genetic Smoking Alcohol E. Management Plan Medication Adjust OHA Metformin: SGLT2 inhibitor: GLP analogues: DPP4 Inhibitor: SULFONYLUREA: Other: Start/adjust Insulin Short acting: Medium acting: Long acting: Basal: Bolus: Anti-hypertensives Statins Others: Lifestyle Dietician referral Exercise prescription Smoking cessation Counseling Diet Exercise Sleep Smoking Alcohol Mental Health Psych consult Therapy for GAD/MDD Mindfulness/CBT Education Diabetes self-care Foot care Hypo/hyperglycemia signs Glucometer training Classes (1–6) F. Behavioral Change Checklist 12 Steps (Self-care) Admitting powerlessness over diabetes Belief in structured support Taking responsibility Daily reflection Comments: 7 Habits (Stephen Covey) Proactive behavior Goal-setting for health Prioritization Win-win plans with caregivers Self-reflection Synergize with team Regular self-renewal (body, mind) 12 Executive Skills Response inhibition Working memory Emotional control Sustained attention Task initiation Planning/prioritizing Organization Time management Goal-directed persistence Flexibility Metacognition Stress tolerance Comments/Plan per skill: Send
