DIABETES CYCLE OF CARE CHECKLIST
Name:<PtFullName> DoB: <PtDoB>
6 Monthly | Date | Date
Measure height, weight and calculate BMI* | |
Measure blood pressure | |
Examine feet | |
Yearly | Date
Measure HbA1c |
Measure cholesterol, triglycerides, HDL cholesterol |
Test for microalbuminuria |
Provide self care education |
Review diet / Healthy Eating Plan |
Review level of physical activity |
Check smoking status |
Review medication |
2 Yearly | Date
Comprehensive eye examination ** |
Claiming | Date | Item No
Date patient last billed for Annual Cycle of Care | |
Seen by: |
Date patient billed for current Annual Cycle of Care | |
Seen by: |

* 	Initial visit:  measure height and weight and calculate BMI as part of the initial assessment.  Subsequent visits: measure weight.
**	Best practice guidelines state annual comprehensive eye examination.

Diabetes Cycle of Care for <PtName> DoB <PtDoB>	Reviewed February 2020	Page