Content Map Terms

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	Whether kidney disease is developing.	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.

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?

Credits

Current as of:
July 28, 2021

Author: Healthwise Staff
Medical Review:
E. Gregory Thompson MD - Internal Medicine
Kathleen Romito MD - Family Medicine
Adam Husney MD - Family Medicine
David C.W. Lau MD, PhD, FRCPC - Endocrinology
Matthew I. Kim MD - Endocrinology