Endocrinology — Diabetes Follow-up Template

Visit Information

Date: [Date]
Visit type: Follow-up
Last visit: [Date]
Diabetes type: Type 1 / Type 2 / Other: [X]
Diabetes duration: [X] years

Current Status

Overall diabetes control: Improved / Stable / Worsening
Patient concerns today: [List]

Glycemic Control

A1c Trend

Date	A1c	Goal
Current	[X]%	[X]%
3 months ago	[X]%
6 months ago	[X]%

A1c at goal: Yes / No — Trend: Improving / Stable / Worsening

Self-Monitoring

SMBG: [X] times/day
Glucose log reviewed: Yes / No

Timing	Average	Range	Target
Fasting	[X]	[X-X]	80-130
Pre-lunch	[X]	[X-X]	80-130
Pre-dinner	[X]	[X-X]	80-130
Bedtime	[X]	[X-X]	90-150
2hr post-meal	[X]	[X-X]	<180

CGM Data (if applicable)

Device: [Dexcom G6/G7, Libre 2/3, Medtronic]
Time in range (70-180): [X]% — Goal: >70%
Time below range (<70): [X]% — Goal: <4%
Time above range (>180): [X]% — Goal: <25%
GMI (Glucose Management Indicator): [X]%
Coefficient of variation: [X]% — Goal: <36%
Average glucose: [X] mg/dL
Patterns identified:

• [ ] Dawn phenomenon
• [ ] Post-breakfast spike
• [ ] Post-lunch spike
• [ ] Post-dinner spike
• [ ] Nocturnal hypoglycemia
• [ ] Other: [X]

Hypoglycemia

Episodes since last visit: None / [X] episodes
Severity: Mild (self-treated) / Moderate / Severe
Timing: [Pattern]
Hypoglycemia awareness: Intact / Impaired
Glucagon available: Yes / No — Trained caregivers: Yes / No

Current Diabetes Medications

Insulin (if applicable)

Insulin	Dose	Timing	Notes
Basal	[Name] [X] units	[Time]
Bolus	[Name] [X] units	[Meals]	ICR: 1:[X]
Correction			ISF: 1:[X]

Pump (if applicable):

• Device: [X]
• Basal rates: [Summary or see download]
• Active time: [X]%
• Reservoir changes: Every [X] days

Non-Insulin Medications

Medication	Dose	Frequency	Issues
Metformin	[X] mg	[X]	[GI tolerance]
GLP-1 RA	[X]	[X]	[Nausea, etc.]
SGLT2i	[X] mg	Daily	[UTI, volume]
DPP-4i	[X] mg	Daily
Sulfonylurea	[X] mg	[X]	[Hypoglycemia]
TZD	[X] mg	Daily	[Edema]

Medication adherence: Good / Fair / Poor — Barriers: [Cost, side effects, complexity]

Lifestyle

Diet

Following meal plan: Yes / Somewhat / No
Carb counting: Yes / No — Accuracy: Good / Fair / Poor
Dietary concerns: [Excessive carbs, irregular meals, portion sizes]
Dietitian visit: Recent / Scheduled / Needed

Exercise

Type: [Walking, gym, etc.]
Frequency: [X] times/week
Duration: [X] minutes
Glucose management with exercise: Good / Issues: [Hypo, hyper]

Weight

Current: [X] kg/lbs
Change since last visit: [+/- X]
BMI: [X]
Weight goal: [X] — On track: Yes / No

Complication Screening

Microvascular

Retinopathy:

Last dilated eye exam: [Date]
Findings: No retinopathy / NPDR (mild/moderate/severe) / PDR
Next exam due: [Date]

Nephropathy:

Last UACR: [X] mg/g — Date: [X]
Category: Normal (<30) / Moderately increased (30-300) / Severely increased (>300)
eGFR: [X] mL/min — CKD stage: [X]
ACEi/ARB: On therapy / Not on therapy / Contraindicated

Neuropathy:

Symptoms: None / [Numbness, tingling, pain, burning]
Monofilament: Intact / Diminished — [R/L]
Vibration: Intact / Diminished
Last foot exam: [Date]

Macrovascular

ASCVD: None / [History]
Last lipid panel: [Date] — LDL: [X]
Statin: On therapy / Not on therapy
Blood pressure: [X/X] — At goal: Yes / No
Aspirin: On therapy / Not indicated / Contraindicated

Other

Dental: Last exam [Date]
Immunizations: Flu [Date], Pneumococcal [Date], COVID [Date]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Weight: [X] — Change: [+/- X] since last visit
BMI: [X]

Focused Exam

General: [Appearance, body habitus]
Thyroid: Normal / [Enlarged]
Cardiovascular: [RRR, no murmurs, edema]
Injection sites: Normal / [Lipohypertrophy, bruising — location]

Foot Exam

Finding	Right	Left
Skin integrity	Intact / [Callus, ulcer]	[Findings]
Dorsalis pedis	Present / Diminished / Absent	[Findings]
Posterior tibial	Present / Diminished / Absent	[Findings]
Monofilament (10g)	[X]/10 sites	[X]/10 sites
Vibration (128 Hz)	Intact / Diminished	[Findings]
Deformity	None / [Description]	[Findings]

Foot risk category: Low / Moderate / High

Assessment

1) Diabetes mellitus, Type [1/2]

• A1c: [X]% — [At goal / Above goal]
• Control: [Improved / Stable / Worsening]
• TIR (if CGM): [X]%

2) Diabetes complications:

• Retinopathy: [Status]
• Nephropathy: [Status]
• Neuropathy: [Status]
• ASCVD: [Status]

3) [Other relevant diagnoses]

Plan

Glycemic Management

Insulin adjustments:

[ ] No changes
[ ] Basal: [Increase/decrease] to [X] units
[ ] Bolus: [Adjust ICR/ISF]
[ ] Add mealtime insulin
[ ] Pump settings: [Changes]

Non-insulin adjustments:

[ ] No changes
[ ] Add: [Medication, dose]
[ ] Increase: [Medication] to [dose]
[ ] Decrease: [Medication] to [dose]
[ ] Discontinue: [Medication] — Reason: [X]

Medication priorities:

• [ ] Maximize metformin
• [ ] Add GLP-1 RA (CV/renal benefit)
• [ ] Add SGLT2i (CV/renal/HF benefit)
• [ ] Intensify as needed for A1c

Technology

[ ] Continue current CGM
[ ] Initiate CGM — Device: [X]
[ ] CGM sensor change education
[ ] Insulin pump evaluation
[ ] Pump adjustment: [Settings]
[ ] Hybrid closed loop discussion

Lifestyle

[ ] Reinforce diet plan
[ ] Carb counting review
[ ] Refer to dietitian
[ ] Exercise recommendations: [X]
[ ] Weight management: [X]

Complication Management

[ ] Schedule dilated eye exam
[ ] Repeat UACR
[ ] Start/optimize ACEi/ARB
[ ] Optimize statin therapy
[ ] Podiatry referral
[ ] Smoking cessation

Labs

[ ] A1c (in [X] months)
[ ] Lipid panel
[ ] BMP/CMP
[ ] UACR
[ ] TSH
[ ] Vitamin B12 (if on metformin)

Referrals

[ ] Diabetes education/DSMES
[ ] Dietitian
[ ] Ophthalmology
[ ] Podiatry
[ ] Cardiology
[ ] Nephrology
[ ] Other: [X]

Patient Education

• Medication changes explained
• Hypoglycemia prevention/treatment
• Sick day rules reviewed
• Foot care
• [Other specific topics]

Follow-up

Return: [X] months

• Labs: A1c [X] days prior
• CGM/pump download at visit

Sooner if: Recurrent hypoglycemia, persistent hyperglycemia, illness