DSMES INTERVENTION TRACKING FORM

Participant Name: Participant 2 Date of Birth: 2/24/1962

Date of DSMES Assessment: 7/29/2022 Learning Needs: Discussion

DSMES PLAN
WHAT TOPICS: ☐ Healthy Coping ☐ Healthy Eating ☐ Being Active ☐ Taking Medication

☐ Monitoring ☐ Problem Solving ☐ Reducing Risks

HOW: ☐ Group ☐ Individual (special needs: Participant learns effectively with one-on-one discussion )

WHERE: ☐ In-person ☐ Telehealth ☐ Telephone (audio-only) WHEN (date of first session): 7/29/2022

Session #1 Session #2 Session #3 Session #4

DATE OF SERVICE:

TIME SPENT:
2
in 30-minute units

INDIVIDUAL OR
GROUP Individual

TOPICS COVERED ☐ Healthy Coping ☐ Healthy Coping ☐ Healthy Coping ☐ Healthy Coping
Check all that ☐ Healthy Eating ☐ Healthy Eating ☐ Healthy Eating ☐ Healthy Eating
apply ☐ Being Active ☐ Being Active ☐ Being Active ☐ Being Active
☐ Taking Medication ☐ Taking Medication ☐ Taking Medication ☐ Taking Medication
☐ Monitoring ☐ Monitoring ☐ Monitoring ☐ Monitoring
☐ Problem Solving ☐ Problem Solving ☐ Problem Solving ☐ Problem Solving
☐ Reducing Risks ☐ Reducing Risks ☐ Reducing Risks ☐ Reducing Risks
Participant The participant will
DSMES Progress eat healthy foods and
and Plan: will walk 2miles 3x/day.

Clinical or Participant is determined

Behavioral with her goal of being
Outcome healthier and not use
insulin in the future.

DSMES Team
Signature: Anna Anderson

S-will avoid chocolates M-walk 2miles 3x/wk A-will eat vegetables and fruits R-will decrease calories
Participant’s SMART goal:____________________________________________________________________
T -will feel better overall in 1 month

Date goal set: 8/29/22 Date of goal follow up: 8/29/22 Goal Progress: Never Met 1 - 2 - 3 - 4 - 5 Always Met

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