DIABETES REPORT

PATIENT:_________________________________________________
SOCIAL SECURITY #:_______________________________________
D.O.B. :____________________________________________________
TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.
1.	Does this patient suffer from diabetes?
	_______Yes _______No If yes,
	A. What is the current diagnosis?
	B. On what date was the diagnoses first made? _______________
	C. What is the date of onset, if different? _________________
	D. How long have you been treating the condition? _____________
	E. What is the most recent date of examination? _______________
	F. What was the patient's height ________ weight _________ at that time?
2.	What lab tests have been performed?

3.	Have tests indicated:
			Yes	No	Date(s)
	A.	Ketosis	_______	_______	_______________________
	B.	Acidosis	_______	_______	_______________________
	C.	Hyperglycemia	_______	_______	_______________________
	D.	Hypoglycemia	_______	_______	_______________________
4.	Has the patient had:
	A.	Visual complications? Yes ____ No ____
		If yes, please describe, with dates:
	B.	Vascular complications? Yes _____ No _____
		If yes:
			Yes	No	Date(s)
		1. Cold feet	_______	_______	_______________________
		2. Ulceration	_______	_______	_______________________
		Location	_______________________________________________
		3. Claudication	_______	_______	_______________________
		4. Gangrene	_______	_______	_______________________
		Location	_______________________________________________
		5. Arteriosclerotic disease	_______	_______	_______________________
		6. Amputation	_______	_______	_______________________
		Location	_______________________________________________
		7. Paresthesia	_______	_______	_______________________
		8. Slow healing of injuries	_______	_______	_______________________
		9. other	_______	_______	_______________________
	C.	Neuropathy? Yes _____ No _____
		If yes, what symptoms have been observed consistent with the diagnosis?

		1.	Tingling: Location ________________ Dates ______________
		2.	Numbness of:	Hands ________________	Date ________________
				Feet __________________	Date ________________
		3.	Patellar and Achilles Tendon Reflexes:	Decreased ____________	Date ________________
				Absent __________________	Date ________________
		4.	Vibration Sense:	Diminished _____________	Date ________________
				Lost __________________	Date ________________
		5.	Frequent "constant aching type" pain:		Date ________________
		6.	Other Symptoms:	_______________	Date ________________
Please describe any sustained abnormality of gait, station, dexterity or motor Function:
	D.	Coma? Yes _____ No ______. If yes, include dates:
	E.	Any other complications? Yes _____ No ______. If yes, describe with dates:
5.	What is the present therapy for the condition:
6.	Does patient comply with therapy? Yes _____ No ______.
7.	What medication is the patient currently taking for the condition?
8.	Are any side effects from the medication observed or reported? Yes ____ No ____. If so, what are they?
9.	Is the diabetes:
		A.	Well controlled __________________
		B.	Somewhat controlled _____________
		C.	Poorly controlled ________________
10.	What has been the response to treatment?
11.	What modification to life style or daily living has been recommended?
12.	From what other medical or psychological conditions does patient suffer in addition to those described above?
13.	Are you treating these conditions? Yes _____ No _____.

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357