Professional Documents
Culture Documents
0/2010
No.
*estimate/presumed
Height cm
Weight kg / /
Waist circumference cm / /
2
Body Mass Index (BMI) kg/m / /
Blood pressure mmHg / /
Random Blood Sugar (RBS) mmol/L / /
Fasting Blood Sugar (FBS) mmol/L / /
2-hour Post Prandial (2HPP) mmol/L / /
HbA1c % / /
Total: mmol/L / /
TG: mmol/L / /
Serum
cholesterol HDL: mmol/L / /
LDL: mmol/L / /
Creatinine mol/I / /
Microalbuminuria Positive / negative / /
Proteinuria Positive / negative / /
Fundus examination Normal / abnormal / /
Foot examination Normal / abnormal / /
ECG test Normal / abnormal / /
Screening for Erectile Dysfuntion Normal / abnormal / /
* Estimate/presumed: If exact date not known and only the year is known, please fill date as 30/06/yyyy and tick the adjacent box
Note: For Diabetes-related complications, date of diagnosis can be at any point in time after
diagnosis of diabetes.
Retinopathy / /
Ischaemic heart disease / /
Cerebrovascular disease / /
Nephropathy / /
Diabetic foot ulcer / /
Amputation / /
Hypertension / /
Dyslipidaemia / /
Others:_________________________ Alpha-blockers
Ticlopidine Statin
Others:_________________________ Fibrate
Others:_________________________
Signature :
Name : Date of audit :
* Estimate/presumed: If exact date not known and only the year is known, please fill date as 30/06/yyyy and tick the adjacent box