Referral to Diabetes Nurse Educator
Referred by Dr ................................................
Date: ................................................
Name of Patient ................................................
HN................................................. Age................................................... Male ☐ Female ☐
T2D................................................ GDM................................................... T1D................................................... HbA1C.................................................
New ☐ Follow up ☐
Diabetes Training Topic:
- Insulin therapy
- Hypoglycemia S&S
- Hyperglycemia
- HGM
- Foot Care
- Sick days
- Travel
- Lifestyle change
- Other
Patient’s Feedback
How does this education session improve your knowledge?
Poor ☐ Fair ☐ Good ☐ Verygood ☐ Excellent ☐
Comments:
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