Basic data
Here you can edit a patient's data if need be.
- To save the new data click on .
- If you want to compile a new sheet, click on .
Date of birth
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Please enter in the format day.month.year. ( i.e. 24.12.2000
)
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Initials
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The first letters of a patient's name (can be for example used when
searching for a patient so it may be quite useful) .
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Gender
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male oder female
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Diabetes-type
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Type 1 = IDDM
Typ 2 = NIDDM (even if it is treated with insulin)
others = pankreoprvic DM, nosologiscally unsolved cases, Gestationaldiabetes
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Diabetes-Diagnosis
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Year of diagnosis of Diabetes (values greater than 1920 or empty
field)
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Insulin since
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Year that insulin therapy was begun(>1926 or empty)
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OAD seit
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Year that oral antidiabetics were begun (values> 1940 or
an empty field if OAD were never taken).
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Note: The orange fields are obligatory
fields.
Physician and Date
To use the data, the blue fields are obligatory,
they must be completely filled out.
Physician-ID
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FQSD-ID of the examining physician
Important! This physician-ID-number is assigned by the center's
administrator. If none has yet been assigned to you, please contact this
person. |
Date
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Creation date of the sheet: The current date is entered as default.
!! Important !!
This date characterizes the sheed an is used in the analyses. If you
enter "old" sheets be sure to enter the correct date.
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Reasons for treating/ examining/ training the patient
Reason
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was the patient admitted to the hospital or treated /examined
/ trained on an out-patient basis?
On the paper-form used during initial examination, other terms may
be used (i.e. consult=out-patient and in-patient= admitted etc). |
Exam-date
( ambulatory) |
Here, the date of the consult/examination / training should
be entered. |
Length of stay ( from, to) (in-patient) |
If the patient was admitted to hospital, the date of admission
and dismissal is entered. |
The appropriate fields in the
list below should be checked. Multiple entries are possible. |
Routine
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Routine check-up
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Manifestation
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Yes/ No |
Patient education
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Admission for structured schooling
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Pregnancy
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In combination with "other" type of diabetes means gestational
diabetes
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Sequaelae
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i.e.: Renal insufficiency, heart attack
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Emergency
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Only emergency means Hypoglycaemia: Glucose or glucagon had to be injected
or medical assistance was needed
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Diab. Foot-syndrome
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Admittance because of diabetic foot syndrome
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Ketoacidosis
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Hyperglycaemic, ketotic metabolic derailment requiring in-hospital
treatment;
(in this case, check "emergency" also)
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others
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Can be defined by a center, must however be documented internally
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Note: mandatory
fields must be filled out.
Pregnancies
These fields should only be filled out if one or more completed pregnancies
occured within the past 12 months.
The following distinctions can be made:
Normal
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Number of normal pregnancies (range: 0-4 or empty)
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Misscarriage
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Number of spontaneous miscarriages or medically indicated abortions
(range: < 10 or empty)
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Deformity
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Number of abnormalities (range: < 10 or empty)
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Perinatal deaths
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Number of perinatal deaths (range: < 10 or empty)
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Note: These numbers refer only to the past 12 months .
Risk factors
(Average of the past 3 months)
If no risk factor was ascertained, these fields can be left empty.
Zigarettes/ day
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Number or estimates, 1 pipe equals 3 cigatettes
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Alcohol: g/ Week
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Amount or estimate (Range :<1000 or empty)
50g / week = occasionally
100g / week = some
200g / week = moderate
300g / week = chronic alcoholism
Additional transformation table:
Drink
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Amount
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g Alcohol
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Schnaps
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1 glass (2 cl)
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7 - 8
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Cognac
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2 cl
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7 - 8
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Whiskey
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2 cl
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7 - 8
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Liqueur
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4 small glasses
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20
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Wine
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1/4 litre
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20
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Wine
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1/2 litre
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40
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Beer
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2 bottles à 0.5 litre
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40
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Self-check
Number of glucose self-checks performed by the patient per week (average
of the past 3 months)
Blood -glucose
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(Range <99 or empty)
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Urin glucose
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(Range <99 or empty)
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Training / Self-help organisations
The entries refer to the last training before the actual time of examination.
The items "nutrition" through to "self-checks" (excluding
"risk factors") must be affirmed to count as structured training
.
No Information
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If checked, the patient is not capable of giving credible information.
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Schooling
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Year of the last schooling prior to the examination (Range:
>1920 or empty)
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Tip: If you select Yes (or No) in the box
, all elements are set to Yes (or No). Then you can simply change those fields
which are still wrong to No (or Yes).
Mesurements
Depending on availability, the following values can be entered here:
- either the last measured values, taken for example at a G.P.,
- or the values taken at admission.
Weight
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Body-weight of the patient in kilogram (range:0-300 or empty)
|
Size
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Height of the patient in cm (range 40-250 or empty) |
BMI |
The Body Mass Index is calculated onhand weight and size and is thus
not entered.
If the entered value is >40, a warning is shown. Combinations resulting
in values > 90 are not allowed.
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Bloodpressure
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Patient`s blood-pressure in mmHg after 5 minutes rest in seated position
with arm elevated/supported
(Ranges: Systolic: 70 - 300 or empty; Diastolic: 30 -
150 or empty)
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Blood glucose
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mg/dl (Range: 0 - 2000, or empty)
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Hb
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Current value in g/l (Range: 3 - 20 or empty)
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HbA1c
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Current value in % (Range: 4 - 40, or empty)
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Creatinin
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Value in mg/dl (Range: 0 - 20 or empty)
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Microalbumin
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Value in mg/l (Range: 0 - 9999 or empty)
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Proteinurea
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Value in g/l (Range: 0 - 30, or empty)
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Cholesterol
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Value in mg/dl or mmol/l (Range: 10 - 2000 or empty)
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HDL-Cholesterol
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Value in mg/dl (Range: 7 - 999, or empty)
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Triglyceride
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Value in mg/dl (Range: 8 - 9999 or empty)
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LDL-Cholesterol
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Value in mg/dl (Range: 10 -400, if no value is entered, the LDL is
automatically calculated using the Friedemann-equation)
LDL-Cholesterol = Cholesterol - HDL-Cholesterol - Triglyceride/5
For immediate display of the calculated LDL-value, click on the button
"calculate".
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fasting
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this value refers to the blood serum lipids
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Note: The units correspond to those on the form. They can however
be individually adapted to each center. These changes can be performed by
the center's administrator under the menu Administration (submenu:
settings).
St.Vincent - endpoints
If symptoms listed below occurred within the last 12 months, enter a Yes in
the respective field.
Blindness
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only if receiving state compensation for blindness
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Heart attack
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Yes/ No
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Stroke
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Hypertension-induced encephalomalacia or haemorrhage, not aneurysm
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termin. kidney failure
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Yes/ No
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Amput. above ankle
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only if the amputation was cuased by the diabetes
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Amput. below ankle
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only if the amputation was cuased by the diabetes
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Tip: If you select Yes (or No) in the box
, all elements are set to Yes (or No). Then you can simply change those fields
which are still wrong to No (or Yes).
Symptoms in the last 12 months
If one of these symptoms occurred in the last 12 months, confirm these with
Yes.
Orthostasis
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Yes/ No
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Angina pectoris
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Yes/ No
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Neuropathy
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Symptoms caused by neuropathy
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Claudicatio
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Yes/ No
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Erectile dysfunktion
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Yes/ No
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Note: Please ensure that for "Erectile dysfunktion" the
"Male" gender was checked in the basic patient data.
Exams - Eyes
Only fill this out if a written result of an exam performed within the past
12 months is available.
Exam within the past 12 months |
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The values have to be entered for RIGHT and LEFT.
ever photocoagulated
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cataract affecting eyesight
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Retina visible
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if the retina is visible:
|
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clinically relevant macular edema
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|
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Retinopathy (3 levels)
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- mild/moderate
- extensive, not proliferative
- proliferative
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advanced ocular damage
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correlates to <20% vision
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vision (in %)
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% vision inkl. correction (range: 0 - 120 or empty)
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Tip:
-
If you select Yes (or No) in the box
, all elements are set to Yes (or No). Then you can simply change those
fields which are still wrong to No (or Yes).
- If you click on the
symbol or the Form for Opthalomologist a new window opens showing you
the form. You can then print it or save it on your hard disc. You must however
have the Acrobat® Reader installed.
Exams - Feet
Should only be filled out if the feet were examined within the past 12 months.
normal vibratory sensation
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Tuning fork examination
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normal pain sensation
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i.e. normal monofilament - test.
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Puls detectable
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Aa. dorsalis pedis (dorsal pedal artery) and Aa. tib. posterior (posterior
tibial artery)
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Healed Ulcer
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Yes/No
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Acute Ulcer
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Yes/No
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Bypass/Dilatation
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Yes/No
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Note: Abnormal vibratory or pain sensation is indicative of diabetic
neuropathy.
Tip: If you select Yes (or No) in the box
, all elements are set to Yes (or No). Then you can simply change those fields
which are still wrong to No (or Yes).
Quality of life / Emergencies
(in the passt 12 months)
Hypoglycaemia
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Incidents per year - glukose or glucagon must have been applied by
somone other than the patient(Range: 0 - 99 or empty)
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Hospitalization due to hypoglycaemia
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Number per year (Range: 0 - 99 or empty)
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Hyperglycaemia
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Number/ Year
hyperglycaemic, ketotic metabolic derailments with hospitalization
or hyperosmolaric emergencies (Range: 0 - 99 or empty)
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WHO-Wellbeing Five
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Indicator for wellbeing (Range: 0 - 25)
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Sick days
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Days per year - indepentant of origin (Range: 0 - 366 or empty)
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Days of hospitalization
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Days per year - indepentant of origin; including the current stay (Range:
0 - 366 or empty)
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Diabetestherapy
Please enter the year of initial therapy in the box (under
initial ) of the respective medication (even if it is not currently
prescribed).
The "yes/no" fields are divided in two columns:
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"To date"
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(this consult) refers to the treatment give up to this point
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"From now"
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(this consult) refers to the treatment prescribed from this point on
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Diet only
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only "yes" if diet is the only treatment form
|
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Biguanides
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Year of first prescription (range>1949 or less)
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Sulfonylureas
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Year of first prescription (range>1949 or less)
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Glukosidase inhibitors
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Year of first prescription (range >1949 or less)
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Other OAD
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Year of first prescription (range >1949 or less)
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Insulin -Units/day
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Number (range: 0 - 999 or less)
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Insulin-Injektions/day
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Number, if under intensified insulintherapy (mixing basal- and normal
insulin), count insulins seperately. (range: 0 - 9 or less)
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Pen
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Yes/ No
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Pump
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Yes/ No
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other treatment |
this item is undefined
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Tip: If you select Yes (or No) in the box ,
all elements in the columnare set to Yes (or No). Then you can simply change
those fields which are still wrong to No (or Yes).
Additional treatment
The "yes/no" fields are divided in two columns:
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"To date"
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(this consult) refers to the treatment give up to this point
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"From now"
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(this consult) refers to the treatment prescribed from this point on
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The additional medication taken by the patient are entered here -subdivided
into groups directly related to diabetes.
Hypertension
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Yes/ No additional therapy
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Heart failure
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Yes/ No additional therapy
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Cor. Heart disease
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Yes/ No additional therapy
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Dyslipidemia
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if requiring more than insulin administration, Yes/ No additional
therapy
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Nephropathy
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if requiring more than insulin administration, Yes/ No additional therapy
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Neuropathy
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if requiring more than insulin administration, Yes/ No additional therapy
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Others
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all other medications taken by the patient and not mentioned above,
additional therapy
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Tip: If you select Yes (or No) in the box ,
all elements in the columnare set to Yes (or No). Then you can simply change
those fields which are still wrong to No (or Yes).
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