HH MD Intake Assessment Template

Introduction:
No significant findings.

Subjective:
Chief Complaint:
Follow-up for diabetes and hypertension management

Medical History:
* Current medical concerns or diagnosis: Type 2 diabetes mellitus, hypertension.

* Past surgical history: No significant findings.

* Past medical history: No significant findings.

* Are you seeing any specialists? No.

* When was your last physical? No significant findings.

Family History:
FAMILY HX: (updates on: 2026-01-27)
Younger brother recently diagnosed with diabetes.

Allergies, Medications and Supplements:
* Do you have any allergies or intolerances? (medication, environment, or food): No known drug allergies.

* Current medications: Metformin, Ramipril. No side effects from metformin and ramipril.

* Current supplements or over the counter medications: No significant findings.

Social History:
* Social history notes updated on 2026-01-27

Relationships status: No significant findings.
Family: No significant findings.
Occupation: No significant findings.
Diet: Patient is trying to eat better, focusing on high-fibre, low-glycemic foods, and limiting salt intake.
Caffeine: No significant findings.
Exercise: Patient walks regularly and is encouraged to add light strength training twice a week.
Alcohol: No significant findings.
Smoking: No significant findings.
Substances: No significant findings.
Sleep: No significant findings.
Stress: No significant findings.
Do you have a strong support network? No significant findings.

Supplements:
No significant findings.

Immunizations and Travel History:
Current Immunizations record:
- dTap: 
- Annual flu: 
- Pneumonia vaccine(s): 
- Shingles: 
- HPV: 
- RSV: 
- Travel vaccines: 

* Travel plans? 

Dietary and Exercise Concerns:
* Dietary restrictions or concerns: Patient is advised to eat high-fibre, low-glycemic foods, avoid sugary drinks, and limit salt intake to about 1 teaspoon per day.

* Exercise routine or challenges: Patient walks regularly and is encouraged to add light strength training twice a week.

Assessment and Plan:
- Discussed importance of controlling diabetes and hypertension to reduce risk of heart attacks, strokes, and kidney disease.
- Reviewed target goals: HbA1c under 7%, blood pressure under 130/80 mmHg, LDL under 2.0 mmol/L.
- Reinforced dietary and exercise recommendations, including limiting sodium intake and increasing physical activity.
- Encouraged patient to continue home blood glucose monitoring and keep a log.
- Referral to dietitian for further dietary guidance.
- No ankle swelling.
- No abdominal tenderness.
- No foot ulcers or skin issues.

- Next steps: Repeat laboratory investigations in 3 months. Patient to bring home glucose log to next visit.

Upcoming Appointment Notes:
* Reviewed upcoming appointment notes: Patient is advised to keep a log of home blood glucose readings and bring it to the next appointment. Labs will be repeated in 3 months. Referral to dietitian for personalized guidance.