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.
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.

Right foot
Left foot
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


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.

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?

Related Information

Credits

Current as of: April 16, 2019

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