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Take Charge of Your Diabetes


 
Record for Sick Days
How oftenQuestionAnswer
Every dayHow much do you weigh today?_____pounds
Every eveningHow much liquid did you drink today?_____glasses
Every morning and every eveningWhat is your temperature?_____ a.m.
_____ p.m.
Every 4 hours or before every mealHow much insulin did you take?Time | Dose
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 hoursWhat is your blood glucose level?Time | Blood
------ glucose
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 hours
or each time
you pass urine
What are your urine ketones?Time | Ketones
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 to 6 hoursHow are you breathing?Time | Condition
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______

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Reminders for Sick Days

Call your health care provider if any of these happen to you:

  • You feel too sick to eat normally and are unable to
    keep down food for more than 6 hours.
  • You're having severe diarrhea.
  • You lose 5 pounds or more.
  • Your temperature is over 101 degrees F.
  • Your blood glucose is lower than 60 mg/dL or
    remains over 300 mg/dL.
  • You have moderate or large amounts of ketones in
    your urine.
  • You're having trouble breathing.
  • You feel sleepy or can't think clearly.

If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room.

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Checks and Goals for Each Visit

Things to Do at Each Visit with Your Health Care Provider

  • Bring your blood glucose record book and go over the readings with your provider.
  • Get an A1C test every 3 months. Write down the result and set a target goal for your next test. (See the sample form)
  • Get your weight checked and write it down. You may want to set a goal for your next visit.
  • Get your blood pressure checked and write it down. You may want to set a goal for your next visit.
  • Get your feet checked at every visit as needed.
  • Bring a list of questions or other things you want to talk about.
  • Bring your reminder sheet about “Things to Do at Least Once a Year” to help keep track of these.

Have your health care provider do these tests and set goals with you. Record dates and the results in the boxes below.

Each Visit—SAMPLE
Tests and GoalsDates and Results
2/1/006/11/009/28/001/5/014/3/01
Blood Glucose (mg/dL)145118180105110
A1c
Test/Goal (%)
9.08.98.4not done8.2
8.08.07.57.5
Weight/Goal
(pounds)
180175172170165
170165165165160

Blood Pressure
(goal: 120/80 mm Hg)

140/90140/86138/84136/82124/80
Foot CheckXXXXX

Each Visit
Tests and GoalsDates and Results
Blood Glucose (mg/dL)
A1c
Test/Goal (%)
Weight/Goal
(pounds)

Blood Pressure
(goal: __/__mm Hg)

Foot Check

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Checks and Goals for Each Year

Things to Do At Least Once a Year

  • Get a flu shot (October to mid-November).
  • Get a pneumonia shot (if you’ve never had one) and every 5 years.
  • Get a dilated-eye exam.
  • Get a foot exam (including check of circulation and nerves).
  • Get a kidney test.
    • Have your urine tested for microalbumin.
    • Have your blood tested for chemicals that measure your kidney function.
    • Get a 24-hour urine test (if your doctor advises).
  • Get your blood fats checked for
    • Total cholesterol.
    • High-density lipoprotein (HDL).
    • Low-density lipoprotein (LDL).
    • Triglycerides.
  • Get a dental exam (at least twice a year).
  • Talk with your health care team about
    • How well you can tell when you have low blood glucose.
    • How you are treating high blood glucose.
    • Tobacco use (cigarettes, cigars, pipes, smokeless tobacco).
    • Your feelings about having diabetes.
    • Your plans for pregnancy (if a woman).
    • Other ______________________

Have your health care provider do these tests and other services for you. You may want to set some goals for these. Record the dates and results in the boxes below.

At Least Once a Year—SAMPLE
Tests and Other ServicesDates and Results
Flu Shot10/2/9910/20/0011/1/01
Urine Protein or Microalbumin (mg)10/2/1999
40
10/20/2000
50
11/1/2001
55
Urine Protein or Microalbumin (mg)1.01.21.1

Total Cholesterol (mg/dL)

190180175
HDL Cholesterol (mg/dL)303540
LDL Cholesterol (mg/dL)150140135
Triglycerides (mg/dL)338300250
Tobacco Use5 cigars a day2 cigars0
Eye Exam (dilated)8/11/199910/1/200010/20/2001
Foot Exam10/2/199910/20/200011/1/2001

At Least Once a Year
Tests and Other ServicesDates and Results
Flu Shot
Urine Protein or Microalbumin (mg)
Urine Protein or Microalbumin (mg)

Total Cholesterol (mg/dL)

HDL Cholesterol (mg/dL)
LDL Cholesterol (mg/dL)
Triglycerides (mg/dL)
Tobacco Use
Eye Exam (dilated)
Foot Exam

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Glucose Log Sheets

Glucose Log Sheet for People Who Do Not Use Insulin

Use this log sheet—or one like it that your health care provider may give you—to keep a record of your daily blood glucose levels.

Week Starting: May 26, 2001

 

Personal target Goal: Fasting 90-130/After meals less then 180
Medicine: Glyburide 10 mg twice a day. glucophage 1000 mg twice a day.
Daily Log—SAMPLE


BreakfastLunchDinnerBedtimeOtherNotes
Blood
Sugar
Blood
Sugar
Blood
Sugar
Blood
Sugar
Blood
Sugar
Mon108118121112
Tues112109*151* Missed evening walk.
Start back tomorrow!
Wed125122130*121
Thurs114129185*242* Sick with flu?
Drinking diet soda.
Ketones negative.
Fri156148135130Feeling better today.
Sat128125*151129
11p.m.
 
* Extra juice made sugar go up.
Sun120119*168133* Lunch at church.

Week Starting _______________

Daily Log
BreakfastLunchDinnerBedtimeOtherNotes
Blood
Sugar
Blood
Sugar
Blood
Sugar
Blood
Sugar
Blood
Sugar
Mon
Tues
Wed
Thurs
Fri
Sat
Sun


Glucose Log Sheet for People Who Use Insulin

Use this log sheet—or one like it that your health care provider may give you—to keep a record of your daily blood glucose levels.

Week Starting: May 26, 2001

Daily Log—SAMPLE
Insulin TypeBreakfastLunchDinnerNotes
DoseBlood
Sugar
DoseBlood
Sugar
DoseBlood
Sugar
MonReg812131874118
NPH20
TuesReg811221044115
NPH20
WedReg810931584161
NPH20
ThursReg811121144110
NPH20
FriReg81022112368*Didn't eat much
lunch – Busy day!
NPH20
SatReg812431614118
NPH20
SunReg9*1752994110*Slept late.
NPH20

Week Starting ___________

Daily Log
Insulin TypeBreakfastLunchDinnerBedtimeOtherNotes
DoseBlood
Sugar
DoseBlood
Sugar
DoseBlood
Sugar
DoseBlood
Sugar
DoseBlood
Sugar
Mon
Tues
Wed
Thurs

Fri
Sat
Sun

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Your Health Care Team

Primary Doctor or Health Care Provider

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Eye Doctor (Ophthalmologist, Optometrist)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Foot Doctor (Podiatrist)

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: _____________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________
__________________________________________________

__________________________________________________

Dentist

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: ______________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: ____________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Dietitian (Registered Dietitian, Nutritionist)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Diabetes Educator (Certified Diabetes Educator)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Counselor

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Other

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

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Contact Us:
  • Centers for Disease Control and Prevention
    1600 Clifton Rd
    Atlanta, GA 30333
  • 800-CDC-INFO
    (800-232-4636)
    TTY: (888) 232-6348
  • Contact CDC-INFO
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC-INFO