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.
Today's measurements
|
Measure
|
Suggested target
|
Today's result
|
|
Weight
|
lbs.
|
lbs.
|
|
Blood Pressure
|
______ / ______
|
______ / ______
|
Home blood glucose testing
Keeping your blood sugar in your target range can help prevent damage to your body. It also helps you prevent low blood sugar by letting you know when you need extra carbohydrates.
|
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.
|
Your test results
Seeing your doctor and having certain tests on a regular schedule can help you watch for and avoid many of the problems caused by diabetes. These are some tests you may need.
|
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.
Upcoming tests/Tests to schedule
It's important to stay up to date with all your tests. These may include an eye exam, a foot exam, a dental exam, a liver function blood test, and a cholesterol test. Talk with your doctor about which tests you need and when you should have them.
|
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
|
|
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Dental exam and cleaning
|
Every 6 months
|
|
|
Liver function blood test
|
Once a year
|
|
|
Other:
|
|
|
Your questions and notes
Be sure to get answers to your questions. Write them here and discuss them with your doctor.
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Questions
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Notes
|
|
How often should I check my blood sugar?
|
|
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What should I do if my blood sugar level is too low?
|
|
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What should I do if my blood sugar level is too high?
|
|
Credits
Current as of: April 30, 2024