Smart Form Template (Text Description)

The screenshot of a diabetes registry template has at the top areas for selecting a diabetes type (type 1, type 2, MODY), the diagnosis date,and the last visit date. On the second row, there are boxes for selecting current treatment (insulin, oral meds, diet only), to put in goals for blood pressure and weight, if the patient uses tabacco, and "Yes" and "No" selections to indicate whether the patient was counseled.

In the third row, there are selections for renal protection (ACE Inhibitors, ARB, Exempt), aspirin (Yes, No, Exempt), and foot care. The foot care has options for Brief Food Inspection, Complete Foot Exam with Monofilament (consisting of options for Never Done, Normal, and Abnormal) and date of complete exam. Below the Renal Protection section is the word "Coumadin" with the options "Yes" and "No" after it.

On the fourth row are options for putting in the Pneumovax Date (or a box indicating it was declined), the Flu Vaccine Date (or a box indicating it was declined), the Eye Care Date, a place for indicating Diabetes Education, and a place for indicating what language the patient speaks at home. Beneath this row is an option for answering Yes or No to whether the patient has been hospitalized during the last 6 months and a field for where; there is also an option for answering Yes or No to whether the patient has visited the ER during the last 6 months and a field for where. Beside this information, is a large box called "Goals."

On the left is a column entitled "Data Discussed," and on the right is a column entitled "Goal." On the far left side are words beside each field in the Date Discussed columns. These words, from top to bottom, are, Exercise, Diet, Meds, Glucose, Foot Check, Weight Loss, Other.

At the very bottom of the Registry is an option for selecting "Add to Registry," and two buttons labeled "Accept" and "Cancel."

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