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Patient's Name
   
 
 
 
Diabetes Mellitus
 
Yes
 
No
 
 
 
A1C
   
 
 
 
Foot Exam
   
 
 
 
Eye Exam
   
 
 
 
ACEI
 
Yes
 
No
 
 
 
CAD w/ PCI
 
Yes
 
No
 
 
 
ASA
 
Yes
 
No
 
 
 
Beta Blocker
   
 
 
 
ACEI
   
 
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