Take Charge of Your Diabetes

Records

• Records for Sick Days
• Reminders for Sick Days
• Checks and Goals for Each Visit
• Checks and Goals for Each Year
• Glucose Record Sheets
• Your Health Care Team

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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.

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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 Goals	Dates and Results
	2/1/00	6/11/00	9/28/00	1/5/01	4/3/01
Blood Glucose (mg/dL)	145	118	180	105	110
A1c Test/Goal (%)	9.0	8.9	8.4	not done	8.2
	8.0	8.0	7.5		7.5
Weight/Goal (pounds)	180	175	172	170	165
	170	165	165	165	160
Blood Pressure (goal: 120/80 mm Hg)	140/90	140/86	138/84	136/82	124/80
Foot Check	X	X	X	X	X

 

Each Visit

Tests and Goals	Dates 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 ______________________

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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 Services	Dates and Results
Flu Shot	10/2/99	10/20/00	11/1/01
Urine Protein or Microalbumin (mg)	10/2/1999 40	10/20/2000 50	11/1/2001 55
Urine Protein or Microalbumin (mg)	1.0	1.2	1.1
Total Cholesterol (mg/dL)	190	180	175
HDL Cholesterol (mg/dL)	30	35	40
LDL Cholesterol (mg/dL)	150	140	135
Triglycerides (mg/dL)	338	300	250
Tobacco Use	5 cigars a day	2 cigars	0
Eye Exam (dilated)	8/11/1999	10/1/2000	10/20/2001
Foot Exam	10/2/1999	10/20/2000	11/1/2001

 

At Least Once a Year

Tests and Other Services	Dates 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

Daily Log—SAMPLE

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

	Breakfast	Lunch	Dinner	Bedtime	Other	Notes
	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar
Mon	108	118	121	112
Tues	112	109		*151		* Missed evening walk. Start back tomorrow!
Wed	125	122	130	*121
Thurs	114	129	185	*242		* Sick with flu? Drinking diet soda. Ketones negative.
Fri	156	148	135	130		Feeling better today.
Sat	128		125	*151	129 11p.m.	* Extra juice made sugar go up.
Sun	120	119	*168	133		* Lunch at church.

 

Week Starting _______________

Daily Log

	Breakfast	Lunch	Dinner	Bedtime	Other	Notes
	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar
Mon
Tues
Wed
Thurs
Fri
Sat
Sun

 

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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 Type	Breakfast		Lunch		Dinner		Notes
		Dose	Blood Sugar	Dose	Blood Sugar	Dose	Blood Sugar
Mon	Reg	8	121	3	187	4	118
	NPH	20
Tues	Reg	8	112	2	104	4	115
	NPH	20
Wed	Reg	8	109	3	158	4	161
	NPH	20
Thurs	Reg	8	111	2	114	4	110
	NPH	20
Fri	Reg	8	102	2	112	3	68	*Didn't eat much lunch – Busy day!
	NPH	20
Sat	Reg	8	124	3	161	4	118
	NPH	20
Sun	Reg	9	*175	2	99	4	110	*Slept late.
	NPH	20

Week Starting ___________

Daily Log

	Insulin Type	Breakfast		Lunch		Dinner		Bedtime		Other		Notes
		Dose	Blood Sugar	Dose	Blood Sugar	Dose	Blood Sugar	Dose	Blood Sugar	Dose	Blood 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: ___________________________________

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Important points: __________________________________

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Eye Doctor (Ophthalmologist, Optometrist)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

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Important points: __________________________________

__________________________________________________

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Foot Doctor (Podiatrist)

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: _____________________________________

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Important points: __________________________________

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Dentist

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: ______________________________________

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Important points: ____________________________________

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Dietitian (Registered Dietitian, Nutritionist)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

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Important points: __________________________________

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Diabetes Educator (Certified Diabetes Educator)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

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Important points: __________________________________

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Counselor

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

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Important points: __________________________________

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Other

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

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Important points: __________________________________

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