tick        My Type of Diabetes is (Please Tick):

 

D1  symbol     Type 1 diabetes         

 

 

D2 symbol     Type 2 diabetes     

 

Impaired glucose tolerance       

 

 

tick   Please Tick What You Do:

 

blood glucose test symbol   I have blood glucose tests              Yes    

 

pills   I take diabetes medication              Yes

 

  I have insulin injections                   Yes

 

 

Blood Glucose Level

 

photo of blood glucose monitor          My 'ideal' blood glucose levels are ___________

 

 

photo of blood glucose monitor          My low blood glucose level would be___________

 

 

photo of blood glucose monitor         My high blood glucose levels would be___________

 

tick     I Look After Myself By (Please Tick):

 

bread  rice     bowl of cereal     fish     fruit   

Eating Healthy Food          Yes

 

people walking for exercise

 

Exercising every day           Yes

 

blood glucose testing

 

Doing Blood Glucose Tests        Yes

 

visiting the doctor

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 _________________________