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Robert Fox (M)
ID 2480 · DOB 07/14/1981 · 45 yrs
2 AllergiesRisk 0.28
(569) 822‑4144 · MST robert.fox@example.com 8642 Yule St, Arvada, CO 80007
Type 2 DiabetesHypertension
Primary provider · Amara Okafor, MD Last visit · 03/10/2026 Coverage · Aetna PPO, verified 09/08/2026
RecordsExpand all
Allergies · 2
Diagnoses · 4
Medications · 3
Vaccines · 6
Vitals
History
Care plan
Timeline Profile Visit His. Orders Clinical Prescri. Task Referral Docs Financial Forms
Search visit history Select dates
To‑do actions3
Today · 09/15/2026
In progress · Office visit note
Dr. Amara Okafor, MD · open in the panel to the right
Awaiting result · Hemoglobin A1c, Lipid panel
Sent to Quest Diagnostics 09:26, results expected 09/17
Pending pharmacy · Metformin 500 mg, 1 tab twice daily, #60, 3 refills
e‑Prescribed to Walgreens, Arvada CO
Previous visits
03/10/26 Signed · Office visit, diabetes follow‑up
A1c 7.4%. Metformin continued. Billed and paid.
11/04/25 Signed · Annual wellness visit
Lisinopril started for hypertension. Billed and paid.
Visit note Forms & assessment
Simple SOAP note Templates
Visit time · Tue, Sep 15, 2026, 9:15 AM Type · In‑person, established patient
Chief complaint
Routine diabetes and blood pressure follow‑up
Subjective
Patient reports good adherence to metformin and lisinopril. Home glucose readings 110–140 mg/dL fasting over the past month. No hypoglycaemic episodes, no polyuria or blurred vision. Walking 30 minutes most days. No chest pain, headache or swelling.
Objective
BP 128/78 mmHg, HR 74, wt 204 lb (down 6 lb since March), BMI 29.3. Diabetic foot exam normal, sensation intact bilaterally. Heart regular rate and rhythm, lungs clear. No peripheral oedema.
Assessment
E11.9 Type 2 diabetes mellitus without complications, controlled
I10 Essential hypertension, controlled
Plan
Continue metformin 500 mg twice daily and lisinopril 10 mg daily. Hemoglobin A1c and lipid panel today. Continue Vitamin D3 2,000 IU daily. Return in 3 months, sooner if readings rise above 180 mg/dL.
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