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 _________________________