DIABETES PARTNERSHIP WORKBOOK

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1 PARTNERSHIP WORKBOOK Funded through and Educational Grant from Sanofi-Aventis U.S. LLC

2 General Information : Street: City: State: Zip: Phone: Cell: In Case of Emergency, Please Notify: Phone: Cell: Relationship: City: State: Zip: Second Emergency Contact: Phone: Cell: Relationship: Health Care Power of Attorney : Address: Phone: Cell: Allergies X ALLERGY REACTION X ALLERGY REACTION None Known Latex Demerol Codeine Morphine Sulfa Insect Stings Penicillin Aspirin

3 DIABETES DASHBOARD 120% 100% 80% A1C WEEKLY PREPRANDIAL 60% 40% 20% 0% QUARTER 1 QUARTER 2 QUARTER 3 QUARTER Preprandial 1 Preprandial 2 Preprandial 3 Preprandial WEEKLY POSTPRANDIAL Post Prandial 1 Post Prandial 2 Post Prandial 3 Post Prandial 4

4 KEY PERFORMANCE INDICATORS Criteria for Diagnosing Type 2 Diabetes Fasting Plasma Glucose greater than or equal to 126 mg/dl after greater than or equal to 8 hours of fasting FPG Or Two hour plasma glucose greater than or equal to 200 mg/dl 2 hrs after ingesting a 75-g oral glucose load in the morning after greater than or equal to an 8 hour overnight fast 2-hr PG Or Random Plasma Glucose greater than or equal to 200 mg/dl plus hyperglycemia symptoms of polyuria, polydipsia, or polyphagia RPG Or Hemoglobin A1C greater than or equal to 6.5% HbA1C Criteria for Diagnosing Prediabetes Fasting plasma glucose between mg/dl after greater than or equal to 8 hours of fasting FPG Or Two hour plasma glucose between mg/dl 2 hrs after ingesting a 75-g oral glucose load in the morning after greater than or equal to an 8 hour overnight fast 2-hr PG Or Hemoglobin A1C between % HbA1C

5 KEY PERFORMANCE INDICATORS Glycemic Target for Nonpregnant Adults Hemoglobin A1C less than or equal to 6.5% HbA1C To achieve this target Fasting plasma glucose less than 110 mg/dl FPG and Two hour post-prandial glucose less than 140 mg/dl 2-hr PPG Inpatient Glycemic Target for Nonpregnant Adults Hospitalized individuals with hyperglycemia in the ICU should target a glucose of mg/dl Glucose Hospitalized individuals with hyperglycemia not in the ICU should target a premeal glucose less than 140 mg/dl and a random plasma glucose of less than 180 mg/dl Premeal PG Random PG Physical Activity Greater than or equal to 150 minutes per week of moderate-intensity exercise Weekly Exercise Dyslipidemia Targets in Patient with Diabetes Treatment targets a LDL-C less than 70 mg/dl Treatment targets non-hdl-c less than 100 mg/dl LDL-C non-hdl-c Blood Pressure Target in Patient with Diabetes Blood pressure goal of 130/80 mmhg BP

6 VISIT WORKSHEET CRITERIA History and Physical Exam Blood Pressure Goal: Weight & BMI Goal: Foot Examination Dilated Retinal Exam Dental HbA1C Goal: Fasting Lipid Panel Goal: Urine Microalbumin/Creatinine Ratio Serum Creatinine Flu Vaccine October 1-March 31 Diabetes Self-Management Education (DSME) Self-Management Goal Assessment Medical Nutrition Therapy (MNT) Assessment of Hyper/Hypoglycemia Review of Current Medications and Medication Adherence FREQUENCY Annually or at the discretion of clinician Annually Every six months Every three months Every three months Annually Annually Annually VISIT DATE / / VISIT DATE / / VISIT DATE / / BP: BP: BP: Wt: BMI: Wt: BMI Wt: BMI Sensory Pulses Sensory Pulses Sensory Pulses A1C: A1C: A1C: Insulin ACEI/ARB Statin ASA Insulin ACEI/ARB Statin ASA Insulin ACEI/ARB Statin ASA Comments Signature/Initials

7 GLYCEMIC WORKSHEET HbA1C (A1C): Reflects the average blood sugar level over the past 3 months. The A1C test measures what percentage of the hemoglobin (a protein in red blood cells that carries oxygen) is coated with sugar. Goal: Less than 7% Preprandial: Prior to a meal. Goal: mg/dl Post Prandial: After a meal.goal: Less than 180 mg/dl AVERAGE A1C AVERAGE PRE- PRANDIAL BLOOD GLUCOSE AVERAGE POST- PRANDIAL BLOOD GLUCOSE QUARTER 1 QUARTER 2 QUARTER 3 QUARTER 4 A1C Preprandial 1 Post Prandial 1 Preprandial 2 Post Prandial 2 Preprandial 3 Post Prandial 3 Preprandial 4 Post Prandial 4

8 DIET WORKSHEET My goal is to consume calories per day. My goal is to consume fat grams per day. HEIGHT (in) BMI AVERAGE WEIGHT AVERAGE GRAMS OF FAT AVERAGE CALORIES AVERAGE GRAMS OF CARBS WEIGHT (kg) CALORIES GRAMS OF CARBS GRAMS OF FAT CALORIES GRAMS OF CARBS GRAMS OF FAT CALORIES GRAMS OF CARBS GRAMS OF FAT CALORIES GRAMS OF CARBS GRAMS OF FAT WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7

9 EXERCISE WORKSHEET Physical Activity Perform at least 150 min/week of moderate-intensity aerobic physical activity spread over greater than or equal to 3 days per week with less than or equal to 2 consecutive days without exercise. Physical Activity Physical Activity Physical Activity

10 MEDICATION WORKSHEET of Medication EXAMPLE: Norvasc # of Pills/Schedule Reason for Start End Medication Dose Morn Noon Eve Bed Date Date 10mg 1 HBP Feb- 13

11 STAY IN TOUCH

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