MY DIABETIC RECORD

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YOUR DETAILS

Full Name: *

Date of Birth: *

Contact Email: *

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DOCTORS

Hemoglobin A1c (HbA1c), this should be below 6.5%.

Date:

HbA1c:

Risk Level:

less than 6.5% low; 6.5-8.5%, medium; 8.5% or more high.

PREVIOUS RESULTS

Date:

HbA1c:

Risk Level:

less than 6.5% low; 6.5-8.5%, medium; 8.5% or more high.

DENTISTS

The Basic Periodontal Examination (BPE).

Date:

Highest Score:

0-1 low; 2-3 medium; 4 or 4* high.

Upper Right:

Upper Anterior:

Upper Left:

Lower Right:

Lower Anterior:

Lower Left:

PREVIOUS RESULTS

Date:

Highest Score:

0-1 low; 2-3 medium; 4 or 4* high.

Upper Right:

Upper Anterior:

Upper Left:

Lower Right:

Lower Anterior:

Lower Left:

NOTES

These numbers range from 0 to 4*. The maximum score in each sextant is recorded. 0 - No periodontal problems. 1 - Bleeding on probing (a sign of gingivitis and poor plaque control). 2 - Calculus (indicating the need for scaling and root planning). 3 - Pockets of 3.5 to 5.5mm (that is early periodontal breakdown). 4 - Pockets of 5.5 to 8.5mm (that is moderately severe periodontal breakdown). 4* - Pockets greater than 8.5mm (that is severe periodontal breakdown with an increased risk that teeth will require extraction).