Insulin Use & Blood Glucose Monitoring

Please provide accurate details regarding the patient’s insulin use and glucose monitoring practices. This information is essential for CMS documentation compliance.

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Patient If

Full Name *

Patient ID or Reference

Clinical Notes *

Insulin Dependency Status *--- Select Choice ---Insulin-Dependent (Type 1)Insulin-Dependent (Type 2)Non-Insulin Dependent (Type 2, Oral Meds)Gestational Diabetes (Insulin Managed)Prediabetes (No Insulin Use)others

If Other, please specify

Testing Frequency *

Blood Glucose Monitoring Frequency *--- Select Choice ---DailySeveral times per weekOccasionallyNot MonitoredOther

If Other, please specify

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