Checklist Template for DIP

A. General Patient Information

Name:

MR #:

Age / Gender:

Date of Admission:

Attending Physician:

Date of Interview:

C. History of Present Illness

Onset, duration & progression of symptoms:

D. Systemic Review – Respiratory

Cough
Dyspnea
Wheezing / Asthma / COPD

D. Systemic Review – Genitourinary

D. Systemic Review – Neurological

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:
YesNo

Frequency:
Severity:

Compliance with medication:
YesNo

Insulin use:
YesNo

Type & dose:

F. Past Surgical History

H. Medicine History

Current medications:
OHA:
Insulin doses:

Good Compliance
Poor Compliance

I. Allergies

None
Yes

Specify:

2. Physical Examination Template

A. General Appearance

B. Vitals

Temp (°C):
Pulse (bpm):
BP (mmHg):
RR (/min):
SpO₂ (%):
Weight (kg):
Height (cm):
BMI:

Checklist Template for DIP

A. General Patient Information

B. Presenting Complaint(s)

C. History of Present Illness

D. Systemic Review – General

D. Systemic Review – Cardiovascular

D. Systemic Review – Respiratory

D. Systemic Review – Gastrointestinal

D. Systemic Review – Genitourinary

D. Systemic Review – Neurological

D. Systemic Review – Musculoskeletal

D. Systemic Review – Skin

D. Systemic Review – Obstetric History

Gynaecological History

Blood Glucose Monitoring

E. Past Medical History

F. Past Surgical History

G. Family History

H. Medicine History

I. Allergies

J. Personal/Social History

J. Psychosocial Screening (Checklists)

GAD-7 (Generalized Anxiety Disorder)

PHQ-9 (Depression)

Disease-related Depressed Mood

2. Physical Examination Template

A. General Appearance

B. Vitals

3. Assessment & Diabetes Management Plan Template

A. Diagnosis

B. Glycemic Control Assessment

C. Labs & Investigations

F. Behavioral Change Checklist

12 Steps (Self-care)

7 Habits (Stephen Covey)

12 Executive Skills