Diabetic Check In HistoryPATIENT NAMEHow do you feel {PATIENT NAME} is feeling overall? Great / Better than ever About the same Could be better No energy / unwellAdditional comments or concerns we need to be aware of ?Is {PATIENT NAME} EATING more or less than usual? More Less About the sameIs {PATIENT NAME} DRINKING more or less than usual? More Less About the sameIs {PATIENT NAME} URINATING more or less than usual? More frequent +/- some accidents Less frequent +/- Few or No accidents About the sameWhich Insulin or Medication are you giving {PATIENT NAME}? NPH / Novolin N Bexecat / Senvelgo Vetsulin PZI / Prozinc Lantus / Glargine Other NoneWhich size of Syringes are you using? (if applicable) U – 100 U – 40 NoneWhat frequency do you give {PATIENT NAME}'s insulin/ medication? When was the last dose of insulin/medication administered? Once a day Twice a day (every 12 hours) OtherTime of last dose AM PMWhen was the last time {PATIENT NAME} ate? AM PMApprox TimeWhich food does {PATIENT NAME} typically eat? Royal Canin Glycobalance Hill’s w/d or Satiety Purina ProPlan Diabetes Other Food (please specify)if other please list food(s) Canned Food Dry Kibble FoodDo you have any difficulties administering {PATIENT NAME}'s insulin / medication? Yes No SometimesDid / Will you bring {PATIENT NAME}'s insulin/ medication with you to the appointment? Yes NoWhat other medications or supplements does {PATIENT NAME} receive? None Just Parasite Preventions Other Medications / Supplements (please list below)Name and frequency of other medications or supplementsDo you need any refill medications or supplies? Not today Yes – listed belowRefill Medications or SuppliesΔ
