metabolic tracking form · 9/3/2015  · blood pressure: _____ fasting lipid profile: _____ has pa...

5
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 1 st year Annually Start of Atypical

Upload: others

Post on 06-Aug-2020

0 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Metabolic Tracking Form · 9/3/2015  · Blood pressure: _____ Fasting lipid profile: _____ Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝ If yes,

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

Page 2: Metabolic Tracking Form · 9/3/2015  · Blood pressure: _____ Fasting lipid profile: _____ Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝ If yes,

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

Page 3: Metabolic Tracking Form · 9/3/2015  · Blood pressure: _____ Fasting lipid profile: _____ Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝ If yes,

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: __________________________________________________________________________________

Page 4: Metabolic Tracking Form · 9/3/2015  · Blood pressure: _____ Fasting lipid profile: _____ Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝ If yes,

© 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: __________________________________________________________________________________

Page 5: Metabolic Tracking Form · 9/3/2015  · Blood pressure: _____ Fasting lipid profile: _____ Has pa ent had a 5% or greater weight gain compared to baseline? Yes ⃝ No ⃝ If yes,

© 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: