Diabetes Medical Management Plan

        My Type of Diabetes is (Please Tick):

 

     Type 1 diabetes         

 

 

     Type 2 diabetes     

 

Impaired glucose tolerance       

 

 

   Please Tick What You Do:

 

   I have blood glucose tests              Yes    

 

   I take diabetes medication              Yes

 

  I have insulin injections                   Yes

 

 

Blood Glucose Level

 

          My 'ideal' blood glucose levels are ___________

 

 

          My low blood glucose level would be___________

 

 

         My high blood glucose levels would be___________

 

     I Look After Myself By (Please Tick):

 

                    

Eating Healthy Food          Yes

 

 

Exercising every day           Yes

 

 

Doing Blood Glucose Tests        Yes

 

Visiting my doctor, my podiatrist, my eye specialist, my dietitian and my

diabetes educator  when I should           Yes    

 

f I need to talk about my diabetes I can talk to: _______________________________________

 

Signed by _________________________