Diabetes Care Plan

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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.
___ Your questions. ___ Other test results, if available.

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

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

Your questions and notes

Be sure to get answers to your questions. Write them here and discuss them with your doctor.

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


ByHealthwise Staff
Primary Medical ReviewerE. Gregory Thompson, MD - Internal Medicine
Adam Husney, MD - Family Medicine
Specialist Medical ReviewerMatthew I. Kim, MD - Endocrinology
David C.W. Lau, MD, PhD, FRCPC - Endocrinology

Current as ofMarch 13, 2017