DIABETES Annual Cycle of Care RECORD

Patient name: 	<PtFullName>						DOB:	<PtDoB>

Address:<PtAddress>

Date completed:  		<TodaysDate>

MBS Diabetes SIP Item:	    (B) 2517	  (C) 2521   (D) 2525      MBS Diabetes Home visit items:  (B) 2518   (C) 2522    (D) 2526

Service Due								

6 MONTHLY
	Date Attended	Date 
Attended	Details
(if necessary)					
Weight height BMI

Blood pressure
	
				OTHER CONSIDERATIONS
Annually	Date Attended	Details
(if necessary)	
Foot examination	
				Self-care education	

YEARLY	Date Attended	Details
(if necessary)		Diet education

		
HbA1c test
	
			Physical activity	

Total chol, TG & HDL	
			Medication review	
		
Microalbuminuria test				Quit Smoking discussed	

BIANNUALLY
	Date Attended	Details
(if necessary)					
Eye examination