DIABETES FLOW SHEET

Patient: [Name, date of birth]
Care team: [Lead clinician, nurse or diabetes educator, pharmacist, dietitian, specialists]

DIAGNOSIS AND TARGETS
Diabetes type: [Type 1, type 2, or another type, and what the diagnosis rests on]
Diagnosed: [Month and year]
Other conditions: [Hypertension, kidney disease, heart disease, heart failure, retinopathy, neuropathy, or none]
Allergies: [Drug and reaction, or none known]
A1c target: [Such as 7.0% or below, or another target and the reason for it]
Blood pressure target: [Such as below 130/80]
LDL target: [Value in mmol/L or mg/dL, or a percentage drop]
Glucose target: [Fasting range, or CGM time in range]
Targets agreed: [Date, and with whom]

VISIT TABLE
One line per visit, oldest first. Put a dash where a test wasn't done.
Units: LDL in [mmol/L or mg/dL], urine ACR in [mg/mmol or mg/g], weight in [kg or lb]
Date · A1c % · BP · Weight, BMI · LDL · eGFR · Urine ACR
[Date] · [A1c] · [BP] · [Weight, BMI] · [LDL] · [eGFR] · [ACR]
[Date] · [A1c] · [BP] · [Weight, BMI] · [LDL] · [eGFR] · [ACR]
[Date] · [A1c] · [BP] · [Weight, BMI] · [LDL] · [eGFR] · [ACR]
[Date] · [A1c] · [BP] · [Weight, BMI] · [LDL] · [eGFR] · [ACR]

GLUCOSE DATA
Monitoring: [Meter, CGM, or none; the device, and how often]
CGM, the 14 days before each visit, time in range 3.9 to 10.0 mmol/L or 70 to 180 mg/dL:
[Date] · [In range %] · [Below range %] · [Wear time %] · [GMI or average glucose]
[Date] · [In range %] · [Below range %] · [Wear time %] · [GMI or average glucose]
Meter readings: [Usual fasting and after-meal ranges, and how many readings]

CHECKS DUE
Eye exam: [Date last done, result, next due]
Foot exam: [Date, monofilament, pulses, skin, risk level, next due]
Kidney: [eGFR and urine ACR, date last done, next due]
Lipids: [Date last done, next due]
Dental: [Date of last visit, next due]
Other tests: [B12 on metformin, thyroid in type 1, or others, with dates]

HYPOGLYCEMIA AND DRIVING
Lows since last visit: [Number, lowest reading, time of day, likely cause]
Severe lows: [Episodes that needed another person's help, with date and treatment]
Awareness: [Feels lows coming on, or reduced awareness, and a score if used]
Glucagon: [Prescribed, date, and who at home can give it]
Driving: [Drives or not; glucose check before driving; what to do if low at the wheel; licensing rules and any report made]

MEDICATIONS AND PROTECTION
Diabetes medicines: [Each drug and dose, or the pump and its mode]
Changes by date: [Date, drug, change, and reason]
Statin: [Drug and dose, not indicated, or declined]
ACE inhibitor or ARB: [Drug, dose, and indication, or not indicated]
SGLT2 inhibitor or GLP-1 receptor agonist: [Drug, dose, and indication such as kidney disease, heart disease, or heart failure, or not indicated]
Aspirin: [For established heart disease, or not indicated]
Pregnancy planning: [Contraception and plans where relevant, and drugs to stop before pregnancy]
Side effects: [Reported, and what was done]

VACCINES, SMOKING, AND MENTAL HEALTH
Influenza: [Date of this season's dose]
Pneumococcal: [Vaccine and date]
Other vaccines: [COVID-19, hepatitis B, zoster, or others due by age and current guidance, with dates]
Smoking and vaping: [Never, former, or current; quit support offered]
Mood and distress: [Tool, score, and date, such as PHQ-2, PHQ-9, or a diabetes distress scale]
Support offered: [Counseling, peer support, referral, or none needed]

SELF-MANAGEMENT AND SICK DAYS
Patient's goals: [In the patient's words, with progress at each visit]
Education and programs: [Topics and dates: lows, foot care, eating plan, carbohydrate counting, injection or pump skills; diabetes education, dietitian, or peer programs]
Sick-day guidance: [Medicines to pause, glucose and ketone checks, when to restart, when to get help, date given]

NEXT STEPS
Due before the next visit: [Tests and referrals, and who arranges them]
Next visit: [Date and type]
Updated by: [Name, credentials, date]