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 and in 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 Blood Urine Cholesterol Other Exams Average Pressure Proteins Enroll in Humana’s blood (Goal: less LDL HDL Triglycerides Eye Exam Foot Exam* Diabetes (microalbumin) Disease glucose than (Goal: less (Goal; (Goal: less (Dilated eye (must be done by Education Management (Goal: less 130/80) than 100) Men= >40mg/dl than150mg/dl) exam) your Primary Care Morton than 7%) Women= Physician or Plant or Program by calling 888-444-9973 >50mg/dl) Endocrinologist) St. A’s 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 The exam does not require a referral when you visit a participating EyeMed or Aetna provider. average blood glucose level over the past 2 to 3 months. The goal is less than 7%. If Please ask the provider to send test results to your physician. you are not within goal, please talk to your physician. LDL cholesterol screening: This annual blood test evaluates the level of low-density Urine Microalbumin: This simple urine test screens for microscopic amounts of lipoprotein (LDL), the so-called “bad” cholesterol in the blood. High LDL levels can lead to heart albumin (protein) in the urine that may point to early signs of kidney disease. If test disease. Using test results, your doctor can monitor your cholesterol and prescribe medication or results are positive, please talk to your physician. lifestyle changes as necessary. If you are not within goal, please talk to your physician.

Dilated Retinal Exam: Diabetes is a leading cause of blindness due to its effects on *Foot exam: People with diabetes sometimes experience circulatory problems, particularly in the retina, the back portion of the eye. An annual dilated eye exam by an their extremities. Minor ulcers in the feet can develop and grow into significant medical problems ophthalmologist or optometrist improves the chance of early detection and treatment. requiring surgery. Having your feet examined by your doctor during all of your routine office visits (This exam is different than a routine eye exam for eyeglasses or contact lenses can prevent serious problems. Talk with your physician any time you have a sore on your because the eye doctor uses special equipment and procedures to examine the blood foot. vessels in your eyes.)

*Important! Submit this Checklist to: Heather Keegan, Humana Patient Advocate/Diabetes CARE Program Coordinator OFFICE # 727-588-6137 FAX # 727-588-6182 Pinellas County Schools Risk Management and Insurance Department 301 4th St. SW, Largo, FL 33770

Pinellas County Schools Diabetes CARE Program March 2008, revised July 2013