Eyes Yes No ☐ ☐ Kidneys Yes No ☐ ☐ Nerves Yes No ☐ ☐ Feet Yes No ☐ ☐ Heart Yes No ☐ ☐ Circulation Yes No ☐ ☐ When was your last appointment with an eye doctor? ________________ When was your last appointment with a dentist? _____________________ What problems or questions do you have concerning your diabetes, or why were you referred for this appointment? Patient Signature_________________________________________________________________
Eyes Yes ☐ No ☐ Kidneys Yes ☐ No ☐ Nerves Yes ☐ No ☐ Feet Yes ☐ No ☐ Heart Yes ☐ No ☐ Circulation Yes ☐ No ☐ When was your last appointment with an eye doctor? ________________ When was your last appointment with a dentist? _____________________ What problems or questions do you have concerning your diabetes, or why were you referred for this appointment? Patient Signature_________________________________________________________________
New-Patient-Health-History-Forms-for-All-Providers.docx