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HomeDiabetes Management Protocol

Diabetes Management Protocol

Diabetes Management Form

Case Details (DMF)

Patient Name

UPID

Contact Number

Email ID

Consultation date

Consultant Name

Healthcoach Name

Age (yrs)

Body weight (Kg)

Height (cms)

BMI

Type of DM

Duration of DM

Sign/Symptoms with duration

H/O Present illness

Comorbidities

HTN

THYROID

CAD

FATTY LIVER

DYSLIPIDEMIA

NONE

Complications

NEUROPATHY

NEPHROPATHY

RETINOPATHY

CARDIOMYOPATHY

NONE

HBA1c Report value

FBS Report value

PPBS Report value

RBS Report value

Treatment History

Allopathic

Ayurvedic

Homeopathic

None

H/O any surgery

Family history

specify the relation if family history present

Agni

Gastric Issue

Bloating

Burps

Passing with ease

Pass with difficulty

None

Acidity

Heartburn

Reflux

Sour Belching

none

Bowel frequency /day

Bowel consistency

Bowel Evacuation
Complete Incomplete

Urine

Normal

frequent

reduced flow

burning

urgency

dribbling

Kostha

Sleep

Sleep timings

Diet

Exercise

Daily water intake

Addiction

smoking

alcohol

tobacco

drugs

tea

coffee

Menstrual History

Day Routine

Vikriti

vata

pitta

kapha

rajas

tamas

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