QI Project on T2D Eligibility Submission Form - Medical Learning Institute Inc

MLI QI Project in TED Eligibility Submission Form

- Step 1 of 3

Please provide us your contact information

Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please tell us about your patient population and their health status

What is the average age of your patient population?

Please provide any descriptive information.

Is your practice gender oriented? (e.g., women's health)

Please provide any descriptive information.

Ethnicity and socioeconomic status of your patients

Please provide any descriptive information.

Total number of patients

Please provide any descriptive information.

Patients suffering from T2D

Please provide any descriptive information.

Current control rates for diabetes

e.g., percentage of patients with HbA1c under 7%

Patients with BMI above target

Please provide any descriptive information.

Prevalence of comorbid conditions (e.g., hypertension, cardiovascular disease)

Please provide any descriptive information.

Please tell us about your clinical practice and work setting

Enter the Website / URL for your practice.

Tell us about the providers and your staff?

Tell us about your geographic location:

Urban
Suburban
Rural
Other

Other demographic considerations

Type of Practice

Family Practice
Internal Medicine
Private Practice
Clinic

Obesity management metrics

Percentage of patients receiving counseling for diet and exercise

e.g., percentage of patients and option details

Percentage of patients with documented BMI and follow-up plans

e.g., percentage of patients and option details

Rates of complications associated with diabetes and obesity

Incidence of diabetic neuropathy

e.g., rate of incidence and optional details

Hospital admissions for diabetes-related issues

e.g., rate of admissions and optional details

Standard protocols for diabetes and obesity management

e.g., details on standard protocols

Medication management practices (types of medications prescribed, adherence rates)

e.g., details medication management practices