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Diabetic Profile

Providing this information will allow Dr. Gee to know about the status of your diabetes.  Often times this is information that you have stored at home and by submitting it now you do not need to bring to your visit.

All of these questions are important.  If you are not familiar with the HbA1c values.  It stands for a glycosylated hemaglobin level, often reported in your blood results as a percentage (ie. 6.5%). 


First Name
Last Name
Date of Birth (xx/xx/xxxx)
Type 1 or Type 2
Diabetic Doctor (PCP, endocrinologist, etc.)
Diabetic Doctor's Phone Number() -
Last Visit with Diabetic Doctor
Next Visit with Diabetic Doctor
HbA1c
Date of HbA1c (xx/xx/xxxx)
Last Blood Glucose Level
How often do you check it?
Last Dilated Eye Exam
Diabetic Medications

Copyright 2012. Gee Eye Care. All Rights Reserved

Gee Eye Care, P.A.                             P.O. Box 18075                    Sugar Land, Texas 77496

Serving Sienna Plantation and surrounding areas