DM CSCS-1
DM CSCS-1
DIABETES MELLITUS
Identification Data:
Ward No. Bed No.: OP/IP No. Date of Admission
Name of the Patient
Age Sex:
Presenting complaints and duration : (ask about DM/DM complications related symptoms)
Past History:
Family History:
1
Personal history:
1. Tobacco use: current/ past/ never
If current user:
Form: smokeless/ smoke/ both Quantity:
Duration of the habit:
if past user reason for quitting:
if never used, history of Passive smoking: Present/ No
3. Physical activity:
Diet history:
Vegetarian/ both veg& non-veg
2
Comment on diet of the individual:
SELF-CARE PRACTICES:
Socioeconomic Details:
Type of family: nuclear/ three generation/ joint. Total. No of family members:
Total Family Income Per capita Income:
Ration Card : Absent/Pink/White
Socioeconomic status:
Environment History:
House: (comment on housing status, in terms of over-crowding, ventilation, In-door pollution)
3
General Examination :
Vitals:
Anthropometry:
Height: Weight: BMI:
Waist circumference: Hip circumference: W/H Ratio:
Examination of foot:( if any cracks, ulcers, corns; loss of sensation, foot wear use)
Management:
4
Advise to the patient
QUESTIONS:
6) Did the person make any changes in his/her lifestyle after the diagnosis?