Follow-Up Visit

    1. Patient Identification

    Name:
    Age:
    Medical Record Number (MRN):
    Date of Last Visit:
    Duration Since Diabetes Diagnosis:

    2. Review of Current Symptoms and Status

    Hypoglycemia episodes:
    Hyperglycemia symptoms:
    Unintentional weight changes:
    Fatigue/Malaise:
    Neuropathic symptoms (numbness, tingling):
    Erectile dysfunction / sexual health:
    Recent hospitalizations / diagnoses:

    3. Medication Review

    Current medications:
    Adherence (missed doses, reasons):
    Side effects experienced:
    Dose adjustments required?

    4. Lifestyle Review

    Dietary habits:
    Exercise routines/barriers:
    Tobacco use status:
    Alcohol consumption:
    Mental health status:

    5. Home Monitoring Review

    SMBG patterns:
    CGM data:
    Monitoring accuracy/frequency:

    6. Clinical Examination

    BMI:
    Blood Pressure:
    Foot Examination:
    Monofilament test:
    Fundoscopic exam:
    Insulin injection site check:

    7. Recent Investigations Review

    HbA1c levels:
    Lipid profile:
    Serum Creatinine / eGFR:
    Urine Albumin:Creatinine Ratio (ACR):
    Liver function tests:

    8. Complications Screening

    Diabetic Retinopathy:
    Nephropathy:
    Neuropathy:
    Cardiovascular screening:

    9. Management and Preventative Care Plan

    Medication adjustments:
    Lifestyle counseling:
    Vaccinations (Influenza, Pneumococcal, Hep B):

    10. Next Follow-Up Arrangements

    Planned interval:
    Investigations before next visit:
    Red flags for earlier review:

    Quick Notes Section