FHCHC

 DPP                                                                                                                                                                                                                                                                                                                      Updated  8Dec10

From  OGTT  Screening  to  ILI  -­‐-­‐>  Step  1:  Intake  Procedure  Checklist
Before  the  Intake Yes No
Has  the  OGTT  Screening  Results  Spreadsheet  been  checked  for  any  pre-­‐diabe@c  hispanic  women  between  the  ages  of  18-­‐55  
(ie  study-­‐eligible  pa@ents)?
Have  all  study-­‐eligible  pa@ents  been  invited  for  an  intake  at  the  clinic  (see  intake  call  script)?
For  more  study-­‐eligible  pa@ents,  has  a  report  been  run  in  PECS  that  lists  all  those  diagonosed  with  pre-­‐diabetes  in  the  past  3  
months?
Has  at  least  30  mins  been  scheduled  for  each  intake?
Have  PECS  forms  for  all  intake  pa@ents  been  printed?  
Have  intake  packets  been  created?
           -­‐  Ques@onnaire  #1:  SF12  Health  Survey
           -­‐  Ques@onnaire  #2:  EQ5D
           -­‐  Ques@onnaire  #3:  Physical  Ac@vity
           -­‐  Pedometer  Tracking  Sheet
             -­‐  Consent  Form
             -­‐  Medical  Labs  and  Informa@on  Checklist
             -­‐  Personal  Informa@on  Sheet
Have  all  files  been  checked  for  #1  &  #2  ques@onnaires  already  filled  out  by  pa@ents  during  their  OGTT  screening?  
Has  the  intake  room  been  set  up?
           -­‐  Body  fat  percentage  scale
           -­‐  Waste  circumference  measuring  tape
           -­‐  Blood  pressure  cuff
           -­‐  Supply  of  pedometers
During  the  Intake Yes No
Have  the  delayed  and  immediate  study  tracks  been  explained  to  the  pa@ent?
Has  the  consent  form  been  explained  thoroughly  to  the  pa@ent?  
Has  the  pa@ent  signed  a  consent  form?
Has  the  pa@ent  received  a  copy  of  the  consent  form?
Have  all  3  ques@onnaires  been  filled  out?
Has  the  pedometer  process  and  tracking  form  been  explained?
Has  a  pedometer  been  given  to  the  pa@ent?
Has  all  the  pa@ent's  bloodwork  been  completed?  If  not,  has  the  pa@ent  been  scheduled  for  lab  work?
             -­‐  OGTT
             -­‐  Lipid  Panel
             -­‐  ALT
             -­‐  AST
             -­‐  Hemaglobin  A1C
           -­‐  Insulin
Have  vitals  been  taken?
Has  bloodpressure  been  taken  twice  and  averaged?
Has  pulse  been  taken?
Has  waist  circumference  been  measured?
Has  weight  been  taken?
Has  height  been  measured?
Has  BMI  been  calculated?
Has  body  fat  percentage  been  calculated?
A`er  the  Intake Yes No
Has  all  data  collected  from  the  Intake  been  entered  in  ILI  Study  Pa@ent  Database?
Have  pa@ents  been  randomized  and  given  delayed  or  immediate  study  group  assignments?
Have  all  pa@ents  been  informed  of  their  study  group?
Have  all  pa@ent  charts  been  given  s@ckers  informing  providers  that  they  are  now  part  of  the  ILI  study?
Have  all  pa@ents  in  the  delayed  study  group  been  set  up  with  their  1st  provider  appointment?
Have  all  pa@ents  in  the  delayed  study  group  been  set  up  with  their  nutri@onist  appointment?
Have  all  pa@ents  in  the  immediate  study  group  been  given  a  reminder  call  for  the  first  nutri@on/exercise  class?