To submit this form, you can email it to your healthcare provider or diabetes educator. Alternatively, you can fax it to the provided fax number or submit it physically at the medical institution. For Olathe Medical Center, the submission details are as follows: Email: diabetes@olathehealth.org, Fax: (913) 791-4201, Address: Olathe Medical Center, 20333 West 151st Street, Olathe, Kansas 66061. Ensure all personal and medical information is accurately entered and the form is signed before submission. Consult your healthcare provider for any specific submission instructions.

There are no specific important dates for this form in 2024 and 2025. This form can be used at any time when diabetes assessment is required.

The purpose of this form is to provide a comprehensive assessment of a patient's diabetes management. It collects personal information, medical history, diabetes history, and current treatment details. This information is used by healthcare providers to tailor diabetes care plans and offer personalized advice to patients.

• 1. Personal Information: Includes fields for name, address, contact details, date of birth, age, sex, and more.
• 2. Medical History: Gathers information about the patient's general health, existing medical conditions, and diabetes-related issues.
• 3. Diabetes History: Collects details about the type of diabetes, year of diagnosis, concerns, and previous education on diabetes management.
• 4. Current Diabetes Treatment: Records current treatment methods, including medication, insulin dosage, and blood glucose testing frequency.
• 5. Physical Activity: Documents the patient's exercise habits, duration, frequency, and intensity of physical activity.
• 6. Nutrition: Includes fields for height, weight, weight goals, and meal plans followed by the patient.
• 7. Risk Factors: Assesses risk factors such as smoking and alcohol consumption.
• 8. Living Will/Advance Directive: Inquires about the presence of a living will or advance directive for healthcare.
• 9. Domestic Violence: Gathers information about any history of domestic violence and current safety concerns.

Failure to submit this form may result in inadequate diabetes management and lack of personalized care. It is important to provide complete and accurate information to ensure proper treatment.

• Inadequate Care: Healthcare providers may lack the necessary information to tailor treatment plans, leading to suboptimal care.
• Delayed Treatment: Without the form, there may be delays in initiating or adjusting diabetes treatment.
• Lack of Comprehensive Records: Failure to submit the form can result in incomplete medical records, affecting future healthcare decisions.

• 1. Outpatient Appointments: Used by healthcare providers during regular outpatient diabetes appointments to assess and update diabetes management plans.
• 2. New Patient Intake: Completed by new patients to provide a comprehensive overview of their diabetes history and current management.
• 3. Diabetes Education: Used by diabetes educators to gather information and tailor educational sessions for patients.
• 4. Ongoing Diabetes Care: Utilized by healthcare providers to maintain updated records and adjust treatment plans as needed.
• 5. Medical Record Keeping: Helps in maintaining complete and accurate medical records related to diabetes management.