Saturday, November 24, 2007

Patient-Physician Partnership Agreement

Patient-Physician Partnership Agreement

PDF This form can be downloaded as a PDF.

To better manage your diabetes through a patient-physician partnership and goal setting.

Medical research and clinical experience have shown that optimal management of diabetes significantly reduces the known complications of this disease, including blindness, heart attack, kidney failure and loss of a limb.

You can expect your physician to provide the following services, which are an essential part of diabetes management.

  • OFFICE VISITS - every three months for reviewing your progress.
  • MONITORING - blood pressure, other vital signs, foot examination and hemoglobin A1c.
  • ANNUAL SCREENING - lipids, microalbuminuria (test for kidney protein), eye examination and monofilament testing (sensory examination of feet).


Weight/Body Mass Index: Current: ________/______ Ideal: _______
Hemoglobin A1c (<> Current: _______ Goal for 6 months: _______
Blood pressure (<> Current: _______ Goal: _______
Total cholesterol (<> Current: _______ Goal: _______
LDL (<> Current: _______ Goal: _______

• Schedule follow-up appointments every three months or as indicated by your doctor.

  • Monitor blood sugars at home at the agreed testing frequency: _______.
  • Work toward attaining the personal goals noted above.
PATIENT SIGNATURE ____________ Date: _______
PHYSICIAN SIGNATURE ____________ Date: _______

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