<<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Screening Site Location(s)

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Diane Chloe McDonald
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2 <<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Screening Site Location(s) PLEASE PRINT: Screening Location #: Site Contact Name: Address: City: State: Zip Code: Telephone: Website: Screening Location #: Site Contact Name: Address: City: State: Zip Code: Telephone: Website: Screening Location #: Site Contact Name: Address: City: State: Zip Code: Telephone: Website: Please keep this form for your records.

3 <<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Participant Consent Form PLEASE PRINT: Name: Have you already been diagnosed with diabetes? Yes No If applicable, are you pregnant? Yes No (IF YES, DO NOT CONTINUE) Have you consumed food or liquid other than water in the past 8 hours? Yes No Would you like us to measure your blood glucose (i.e. blood sugar) level? Yes No Would you like us to contact your physician with the results of the assessment? Yes No If yes, please provide physician information: Physician's Name: Address: City/Zip: Daytime Phone: ( ) I hereby authorize the pharmacists and student pharmacists conducting today s screening event to assess my risk of diabetes. Also, if I have indicated that I would like my blood glucose level measured, I understand that a blood sample must be obtained by pricking my finger. I authorize the pharmacists or student pharmacists conducting today s screening to obtain the blood sample and to conduct appropriate tests to measure my blood glucose level. I am participating in this event on a voluntary basis, and understand that the risks associated with this testing are that of a sore finger at the site of blood sampling. I authorize the organizing body and/or pharmacists, and/or student pharmacists, the release of my results to my physician as I have indicated above. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in this event. Signature: Date:

4 American Diabetes Association Type 2 Diabetes Risk Assessment Form Take this test to see if you are at risk for having type 2 diabetes. Type 2 Diabetes is more common in African Americans, Hispanics/Latinos, American Indians, Asian Americans, and Pacific Islanders. 1) How old are you? Less than 40 years (0 points) years (1 point) years (2 points) 60 years or older (3 points) 2) Are you a man or a woman? Man (1 point) Woman (0 points) 3) If you are a woman, have you ever been diagnosed with gestational diabetes? Yes (1 point) No (0 points) 4) Do you have a mother, father, sister, or brother with diabetes? Yes (1 point) No (0 points) 5) Have you ever been diagnosed with high blood pressure? Yes (1 point) No (0 points) 6) Are you physically active? Yes (0 points) No (1 point) 7) What is your weight status? (see chart on next page) Write your score in the box

5 Height (ft & in) Weight (lbs) (1 Point) (2 Points) (3 Points) You weigh less than the amount in the left column (0 points) Bang H, Edwards AM, Bomback AS, et al. A self-assessment diabetes score: development, validation, and comparison with other diabetes risk-assessment scores. Ann Intern Med. 2009;151; If you scored 5 or higher: You are at increased risk for having type 2 diabetes. However, only your doctor can tell for sure if you do have type 2 diabetes or prediabetes which is a condition that precedes type 2 diabetes in which blood glucose levels are higher than normal. Talk to your doctor to see if additional testing is needed. Prevention of type 2 diabetes: Lifestyle modifications have been shown to be very effective in reducing risk of developing type 2 diabetes. Some lifestyle interventions may include: weight loss of 7% body weight, moderate physical activity at least 150 minutes per week (about 30 minutes a day, 5 days a week), and certain medications that your doctor can discuss with you.

6 <<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Patient Assessment Form Today s Date: Patient's Name: DOB: Age: M/F: Tobacco Use: Vaccine Received? Y/N If Yes, date received? If No, recommended? Influenza Tdap Pneumococcal Zoster Hepatitis B (3 dose series) Diabetes Risk Score (from ADA Risk Assessment Form): Blood Glucose: A1C: Type of Test: Fasting ( 8 hours since last food/drink intake) Non-Fasting (< 8 hours since last food/drink intake) Action Plan and Notes for Patient: Referral information (if applicable): Appointment scheduled with: Telephone: Date/Time: Pharmacist referring Patient: Pharmacist s contact information: Note: Please take a copy of this form with you to your next physician s office visit and discuss with your primary care physician.

<<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Event Log Sheet Event Date: Location: Age/Sex/Race ADA Risk Score Fasting?

7 <<UNIVERSITY X>> Operation Diabetes APhA Academy of Student Pharmacists (APhA ASP) SAMPLE Event Log Sheet Event Date: Location: Age/Sex/Race ADA Risk Score Fasting? (Y/N) Blood Glucose/ A1C Level Referral? (Y/N) Other 1 1 Possible notations under other might include whether or not vaccines were administered or any diabetes signs and symptoms that were noted.

8 My Medication-related Action Plan Patient: Doctor (Phone): Pharmacy/Pharmacist (Phone): Date Prepared: The list below has important Action Steps to help you get the most from your medications. Follow the checklist to help you work with your pharmacist and doctor to manage your medications AND make notes of your actions next to each item on your list. Action Steps What I need to do Notes What I did and when I did it My Next Appointment with My Pharmacist is on: (date) at AM PM This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This MAP may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein

9 My Medication record side 1 Name: Birth date: Include all of your medications on this reord: prescription medications, nonprescription medications, herbal products, and other dietary supplements. Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers. LOGO Drug When do I take it? Take for... Start Date Stop Date Doctor Special Instructions Name Dose Morning Noon Evening Bedtime This sample Personal Medical Record (PMR) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the PMR or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the PMR is not a substitute for obtaining professional healthcare advice or treatment. This PMR may not be appropriate for all patients (or other users). The National Association of Chain Drug Stores Foundation and the American Pharmacists Association assume no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

10 My Medication record side 2 Name: Birth date: Phone: Always carry your medication record with you and show it to all your doctors, pharmacists and other healthcare providers. Emergency Contact Information Name Relationship Phone Number Primary Care Physician Name Phone Number Pharmacy/Pharmacist Name Phone Number Allergies What allergies do I have? (Medicines, food, other) What happened when I had the allergy or reaction? Other Medicine Problems Name of medicine that caused problem What was the problem I had with the medicine? When you are prescribed a new drug, ask your doctor or pharmacist: What am I taking? What is it for? When do I take it? Are there any side effects? Are there any special instructions? What if I miss a dose? Notes: Date last updated Patient s Signature Healthcare Provider s Signature Date last reviewed by healthcare provider

My Passport. Name: Date of birth:

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