Patient-Physician Partnership Agreement

Patient-Physician Partnership Agreement

This form can be downloaded as a PDF.

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

REASON
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.

EXPECTATIONS
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).

PERSONAL GOALS

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

YOUR RESPONSIBILITIES
• 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:	_______