Diabetes Care Plan
Your Plan
Your name: __________________
Date: _______________________
You can make the most of your office visit by having this form with you when you talk with your doctor.
What to bring to every appointment
- Your blood sugar log.
- A list of all your medicines, vitamins, supplements, and herbal remedies.
- Other test results, if available.
- Your questions.
|
Measure |
Suggested target |
Today's result |
|---|---|---|
|
Weight |
lbs. |
lbs. |
|
Blood Pressure |
______ / ______ |
______ / ______ |
|
Time of day |
Target range |
Your goal |
|---|---|---|
|
After waking and before eating. |
80–130 mg/dL |
mg/dL |
|
2 hours after a meal. |
Less than 180 mg/dL |
mg/dL |
|
Another time of day: |
mg/dL |
mg/dL |
|
Other: |
mg/dL |
mg/dL |
|
Other: |
mg/dL |
mg/dL |
|
Call your doctor if your blood sugar is below __________ mg/dL or above __________ mg/dL. |
||
|
Test |
What it shows |
Guideline range |
Your result |
|---|---|---|---|
|
A1c |
How steady your blood sugar levels have been over time. |
Less than 7% for most men and for most women who are not pregnant |
_____% |
|
Cholesterol |
The amount and type of fat in the blood. |
mg/dL |
mg/dL |
|
Albumin-creatinine ratio |
Whether kidney disease is developing. |
Less than 30 mg/g |
mg/g |
|
Blood creatinine |
Greater than 90 mL/min |
mL/min |
|
|
Other: |
|
|
|
Your foot exam results
Over time, high blood sugar can damage the nerves and blood vessels in your feet. Check your feet every day to help keep them healthy. Ask your doctor to do a foot exam at every visit.
|
Test |
How often |
Date |
|---|---|---|
|
Complete eye exam |
Once a year. If you don't have any signs of diabetic retinopathy, your doctor may recommend an exam every 2 years. |
|
|
Complete foot exam |
Once a year |
|
|
Dental exam and cleaning |
Every 6 months |
|
|
Liver function blood test |
Once a year |
|
|
Other: |
|
|
|
Questions |
Notes |
|---|---|
|
How often should I check my blood sugar? |
|
|
What should I do if my blood sugar level is too low? |
|
|
What should I do if my blood sugar level is too high? |
|
Current as of: August 31, 2020
Author: Healthwise Staff
Medical Review:E. Gregory Thompson MD - Internal Medicine & Adam Husney MD - Family Medicine & Kathleen Romito MD - Family Medicine & Matthew I. Kim MD - Endocrinology & David C.W. Lau MD, PhD, FRCPC - Endocrinology
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