1 Diabetic care follow up 2018 Date ......../....../20..... Personal data
Name ......................................................... Age............... Sex ............... residence ............................... occupation................. Special habits.............................................
Diabetes mellitus information
Social history
Medications history
Screening
Type.............. Duration............... Treatment regimen ..............................................
Eating pattern and Wight
.................................................................................... .................................................................................
Sleep behavior and physical activity
.................................................................................... ..................................................................... ........... .
Medication-taking behavior
.................................................................................... ..................................................................... ...........
Medication intolerance or side Effects
.................................................................................... ..................................................................... ...........
Complementary and alternative medicine use
.................................................................................... ..................................................................... ...........
Hypoglycemia Timing..................... awarenees............ frequency................ ...... causes....... .................................................................................................................. Pregnancy planing Contraceptive need
................................................
Preconception planing
................................................