APPENDIX: TRACKING FORMS & TEMPLATES
Appendix H
Disease-Specific Monitoring Form
_________________________________________________________________________
For readers managing Diabetes, Cardiovascular Disease, or Cancer alongside their transformation program. Bring this form to all medical appointments.
Name: _________________ Condition: _________________ Physician: _________________ Medications: _____________________________________________________________
Date of this review: _____________ Next scheduled appointment: _____________
DIABETES MONITORING
| Parameter | Target | Last result | Date | This result | Date | Change |
|---|---|---|---|---|---|---|
| Fasting glucose (mg/dL) | < 100 | |||||
| HbA1c (%) | < 6.5 (managed) / < 7.0 (practical) | |||||
| Postprandial glucose 2hr (mg/dL) | < 140 | |||||
| HOMA-IR | < 2.0 | |||||
| Blood pressure (mmHg) | < 130/80 | |||||
| Triglycerides (mg/dL) | < 150 | |||||
| eGFR (kidney function) | > 60 mL/min | |||||
| CGM time-in-range (%) | > 70% (70–180 mg/dL) | |||||
| Foot inspection completed | Weekly | ☐ Yes ☐ No | ||||
| Medication dose changed | ☐ Yes ☐ No | Details: |
CARDIOVASCULAR MONITORING
| Parameter | Target | Last result | Date | This result | Date | Change |
|---|---|---|---|---|---|---|
| Blood pressure (mmHg) | < 120/80 | |||||
| LDL-C (mg/dL) | < 100 (< 70 high-risk) | |||||
| HDL-C (mg/dL) | > 50 (women) / > 40 (men) | |||||
| Triglycerides (mg/dL) | < 150 | |||||
| ApoB (mg/dL) | < 80 | |||||
| hs-CRP (mg/L) | < 1.0 | |||||
| Resting heart rate (bpm) | 50–70 | |||||
| VO₂ max estimate | Improving trend | |||||
| Ankle-brachial index (ABI) | > 0.9 | |||||
| Cardiac symptoms since last visit | ☐ Yes ☐ No | Details: |
CANCER SURVIVORSHIP MONITORING
| Parameter | Target | Last result | Date | This result | Date | Change |
|---|---|---|---|---|---|---|
| Tumor marker (specify): _______ | < _______ | |||||
| Imaging / scan date | Per oncologist schedule | |||||
| Weight (maintain / lose / gain) | Per oncologist goal | |||||
| Fatigue level (0–10) | Trending down | |||||
| Exercise sessions/week | ≥ 3 | |||||
| Protein intake (g/kg/day) | ≥ 1.5 | |||||
| Bone density (DEXA) | Per oncologist schedule | |||||
| Lymphedema assessment | If applicable | ☐ Present ☐ Absent |
Questions to ask my doctor at next visit:
Lifestyle changes since last visit to report: