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Outpatient Diabetes Self-management Education/Training (DOME/T) Order 660 N. Westmoreland Road Lake Forest, Illinois 600451696 Outpatient Medical Nutrition Therapy (MNT) Order Patient information

How to fill out outpatient diabetes selfmanagement

To fill out the outpatient diabetes self-management form, follow these steps:

1. Begin by providing your personal information such as your name, date of birth, and contact details.
2. Next, indicate your current medical condition and specify that you have diabetes.
3. Describe any medication you are currently taking for diabetes management, including the name, dosage, and frequency.
4. Provide details about any allergies or adverse reactions you have experienced with certain medications or treatment options.
5. Indicate if you have any other medical conditions or complications related to diabetes, such as kidney problems or neuropathy.
6. Specify your blood sugar monitoring routine, including the frequency of testing and any devices or tools you use.
7. Describe your dietary habits and any specific meal plans or restrictions you follow to manage your diabetes.
8. Detail your physical activity routine, including the type, duration, and frequency of exercise or sports you engage in.
9. Provide information about any diabetes education programs or classes you have attended to enhance your self-management skills.
10. Lastly, sign and date the form to confirm that the information provided is accurate and complete.

Outpatient diabetes self-management is necessary for individuals who have been diagnosed with diabetes and are not admitted to a hospital or medical facility. It is particularly important for those who:

1. Have recently been diagnosed with diabetes and require guidance on managing their condition outside of a hospital setting.
2. Have chronic or long-term diabetes and need to monitor their blood sugar levels, medication, and lifestyle consistently.
3. Have experienced complications related to their diabetes and require ongoing self-management to prevent further deterioration.
4. Are looking to improve their knowledge and skills in managing diabetes through education and support.

Outpatient diabetes self-management ensures that individuals with diabetes have the necessary tools, information, and resources to effectively manage their condition and maintain a healthy lifestyle outside of a healthcare facility.

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