metabolic tracking form · 9/3/2015 · blood pressure: _____ fasting lipid profile: _____ has pa...
TRANSCRIPT
Metabolic Tracking Form(Based on ADA/APA Guidelines)
© 2015. Developed by Dr. Saundra Jain, MA, PsyD, LPC and Dr. Rakesh Jain, MD, MPH 1
4-weeks
8-weeks
12-weeks
Quarterly for 1st
yearAnnuallyStart of
Atypical
Ref: https://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf
Definition of Metabolic Syndrome
2© 2015. Developed by Dr. Saundra Jain, MA, PsyD, LPC and Dr. Rakesh Jain, MD, MPH
CRITERIA
WAIST CIRCUMFERENCE
GUIDELINES
Baseline, 4-Week and 8-Week Follow-up Form
© 2015. Developed by Dr. Saundra Jain, MA, PsyD, LPC and Dr. Rakesh Jain, MD, MPH 3
BASELINE ASSESSMENT EVALUATION: Today’s Date:
4 WEEK FOLLOW-UP: Today’s Date:
8 WEEK FOLLOW-UP: Today’s Date:
Date atypical started: ____________________________ Waist circumference: ______________________ inchesCurrent atypical name and dose: ___________________ Blood pressure: _________________________________Pertinent personal / family history: _________________ Fasting plasma glucose and A1C: ___________________Pertinent physical exam / findings: __________________ Fasting lipid profile / pertinent findings: _____________Current weight: ___________lbs BMI: _____________ What is 5% weight gain in pounds? _________________
DOES PATIENT HAVE METABOLIC SYNDROME AT BASELINE? Yes ⃝ No ⃝ (see definition on page 1)
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
Today’s weight: ___________lbs BMI: _____________
Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝If yes, next steps: _____________________________________________________________________________
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
Today’s weight: ___________lbs BMI: _____________
Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝If yes, next steps: _____________________________________________________________________________
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
© 2015. Developed by Dr. Saundra Jain, MA, PsyD, LPC and Dr. Rakesh Jain, MD, MPH 4
12-Week and Quarterly Follow-up Form
12 WEEK FOLLOW-UP: Today’s Date:
Today’s weight: ___________lbs BMI: _____________ Fasting glucose / A1C: ___________________________Blood pressure: ________________________________ Fasting lipid profile: _____________________________
Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝If yes, next steps: _____________________________________________________________________________
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
QUARTERLY FOLLOW-UP: Today’s Date:
Today’s weight: ___________lbs BMI: _____________
Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝If yes, next steps: _____________________________________________________________________________
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
QUARTERLY FOLLOW-UP: Today’s Date:
Today’s weight: ___________lbs BMI: _____________
Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝If yes, next steps: _____________________________________________________________________________
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
© 2015. Developed by Dr. Saundra Jain, MA, PsyD, LPC and Dr. Rakesh Jain, MD, MPH 5
Annual Follow-up Form
ANNUAL FOLLOW-UP: Today’s Date:
Date atypical started: ____________________________ Waist circumference: ______________________ inchesCurrent atypical name and dose: ___________________ Blood pressure: _________________________________Pertinent personal / family history: _________________ Fasting plasma glucose and A1C: ___________________Pertinent physical exam / findings: __________________ Fasting lipid profile / pertinent findings: _____________Current weight: ___________lbs BMI: _____________ Gained >5% weight compared to baseline? Yes ⃝ No ⃝
DOES PATIENT HAVE METABOLIC SYNDROME AT ANNUAL FOLLOW-UP? Yes ⃝ No ⃝
Specific Recommendations: 1. Nutritional: ______________________________________________________________________________2. Exercise: ________________________________________________________________________________3. Referral to PCP / Specialist? Yes ⃝ No ⃝4. Other: __________________________________________________________________________________
NOTE: EVALUATIONS CAN BE DONE MORE FREQUENTLY IF NEEDED
NOTES: