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 and natural health products.

___

Your questions.

___

Other test results, if available.

Today's measurements

Measure

Suggested target

Today's result

Weight

kg

kg

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 for most non-pregnant adults

Your goal

After waking and before eating.

4.0-7.0 mmol/L

mmol/L

2 hours after a meal.

5.0-10.0 mmol/L or 5.0-8.0 mmol/L if A1c targets are not being met

mmol/L

Another time of day:

mmol/L

mmol/L

Other:

mmol/L

mmol/L

Other:

mmol/L

mmol/L

Call your doctor if your blood sugar is below __________ mmol/L or above __________ mmol/L.

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.

7% or less for most men and for most women who are not pregnant

_____%

Cholesterol

The amount and type of fat in the blood.

LDL 2.0 mmol/L or less

mmol/L

Albumin-creatinine ratio

Whether kidney disease is developing.

Less than 2.0 mg/mmol

mg/mmol

Blood creatinine

Estimated glomular filtration rate (eGFR) greater than 60 mL/min

mL/min

Other:




Your foot examination 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 examination 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 examination, a foot examination, a dental examination, 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 examination

Once a year. If you don't have any signs of diabetic retinopathy, your doctor may recommend an examination every 1 to 2 years.


Complete foot examination

Once a year


Dental examination and cleaning

Once or twice a year, depending on your dentist's recommendations





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

Credits

ByHealthwise Staff
Primary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine
Kathleen Romito, MD - Family Medicine
Adam Husney, MD - Family Medicine
Specialist Medical Reviewer David C. W. Lau, MD, PhD, FRCPC - Endocrinology
Matthew I. Kim, MD - Endocrinology, Diabetes and Metabolism

Current as ofDecember 7, 2017