FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Treatment Flow Sheet: Diabetes
NAME OF YOUTH: ______________________________ DJJID #: ______________________________
FACILITY NAME: _______________________________ ALLERGIES:____________________________
Who made the diagnosis? _______________________________________________________________________________
When and where was it diagnosed? _______________________________________________________________________
If diagnosed prior to commitment, who most recently treated the condition? ________________________________________
When? ______________ Where? _________________________________________________________________
What treatment was ordered? _____________________________________________________________________
When was treatment last received? _________________________________________________________________
When were symptoms last experienced? _____________________________________________________________
Prior treatment confirmed by: Old records in chart Report from facility or MD’s office
Parent/guardian Youth’s account
Age of onset: _________
Type: _______________ Contributing factors: _______________________ Complications: ___________________________
Visit date:
Next appointment:
Patient teaching
documented?
Diet:
Other restrictions?
Special needs?
Alert log listing?
Chart cover, H&P,
and Problem List
show condition
Height:
Weight:
Blood Pressure
Heart Rate
T & R wnl?
Date of annual
work-up
BMP result
Serum Cr result
Date of annual
fundoscopic exam?
Fundoscope results
Hyperglycemic
episodes?
Hypoglycemic
episodes?
ER or hospital since
last visit?
Insulin?
Oral anti-diabetic
medication?
Compliant w/ tx?
FORM HS 035
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REV. 10/06