Diabetes Care Checklist

Diabetes CARE Checklist

Name: ______

The goal of the Diabetes CARE program is to help you manage your diabetes and stay healthy. Use this checklist to record the dates of each screening. You will need to submit this Checklist to the PCS Diabetes CARE Coordinator*along with your course completion certificate once a year as proof of your commitment andin order to continue participation in the program. List the providers name only. Do NOT list your screening results as this is your private medical information.

A1c
Average blood glucose(Goal: less than 7%) / Blood Pressure
(Goal:less than 130/80) / Urine Proteins (microalbumin) / Cholesterol / Other Exams
LDL
(Goal: less than 100) / HDL
(Goal;
Men= >40mg/dl
Women= >50mg/dl) / Triglycerides
(Goal: less than150mg/dl) / Eye Exam
(Dilated eye exam) / Foot Exam*
(must be done by your Primary Care Physician or Endocrinologist) / Diabetes Education
Morton Plant or St. A’s / Enroll in Humana’s Disease Management Program by calling 888-444-9973
Date
Provider
Name or location

Listed goals are the recommended values for people with diabetes.Goals and recommendations are based on American Diabetes Association 2008 guidelines for a nonpregnant adult.

Glycosylated Hemoglobin or Hemoglobin A1c: This blood test measures the average blood glucose level over the past 2 to 3 months. The goal is less than 7%. If you are not within goal, please talk to your physician.
Urine Microalbumin: This simple urine test screens for microscopic amounts of albumin (protein) in the urine that may point to early signs of kidney disease. If test results are positive, please talk to your physician.
Dilated Retinal Exam:Diabetes is a leading cause of blindness due to its effects on the retina, the back portion of the eye. An annual dilated eye exam by an ophthalmologist or optometrist improves the chance of early detection and treatment. (This exam is different than a routine eye exam for eyeglasses or contact lenses because the eye doctor uses special equipment and procedures to examine the blood vessels in your eyes.) / The exam does not require a referral when you visit a participating EyeMed or Aetna provider. Please ask the provider to send testresults to your physician.
LDL cholesterol screening:This annual blood test evaluates the level of low-density lipoprotein (LDL), the so-called “bad” cholesterol in the blood. High LDL levels can lead to heart disease. Using test results, your doctor can monitor your cholesterol and prescribe medication or lifestyle changes as necessary. If you are not within goal, please talk to your physician.
*Foot exam:People with diabetes sometimes experience circulatory problems, particularly in their extremities. Minor ulcers in the feet can develop and grow into significant medical problems requiring surgery. Having your feet examined by your doctor during allof your routine office visits can prevent serious problems. Talk with your physician any time you have a sore on your foot.

*Important!Submit this Checklist to:Heather Keegan, Humana Patient Advocate/Diabetes CARE Program Coordinator

OFFICE # 727-588-6137 FAX # 727-588-6182Pinellas County SchoolsRisk Management and Insurance Department

301 4th St. SW, Largo, FL 33770

Pinellas County Schools

Diabetes CARE Program

March 2008, revised July 2013