NDR/Update/version_1.

0/2010

DIABETES OUTCOME UPDATE FORM

Health Facility :

Name of patient : IC No. :

Not If Present, date of Estimate/

Complication Present Absent
known diagnosis presumed

Retinopathy / /
Ischaemic heart disease / /
Cerebrovascular disease / /
Nephropathy / /
Diabetic foot ulcer / /
Amputation / /
Not If Yes, date of Estimate/
Concomitant Co-Morbidity Yes No
known diagnosis presumed

Hypertension / /
Dyslipidaemia / /
Smoking status

Follow-up Status

On active follow-up

Loss to follow-up Transferred care (government)

Date of last visit: ______________ Transferred care (private)

Self-treatment

Others

Reason not known

Died Related to Diabetes

Date of death: ________________ Not related to Diabetes

Not known

Signature:

Name: Date:

* 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