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Your Guide to Diabetes: Type 1 and Type 2

Your Diabetes Care Records

On this page:

Make copies of the charts in this section. These charts list important things you should discuss with your doctor at each visit.

Things to Discuss with Your Health Care Team at Each Visit


Date: _______________

Whom you visited: __________________________________




Your information
 

Things to remember
 

 Check off what you covered, or write the result of your visit. 
 
Your blood glucose levels
  • Share your blood glucose records. Your doctor will ask how you are checking your blood glucose levels to make sure you are doing it right.
  • Mention if you often have low or high blood glucose.

 empty checkbox Shared blood glucose records?
 empty checkbox Checked meter?
 empty checkbox Practiced blood glucose reading?
 empty checkbox Shared high or low blood glucose?
 
Your weight
  • Talk about how much you should weigh.
  • Talk about ways to reach your target weight that will work for you.

 empty checkbox My weight now is _____________.
 empty checkbox My target weight is _____________.
 empty checkbox Steps to take:
 
 
Your blood pressure
  • Ask about ways to reach your target.
  • The target for most people with diabetes is below 140/80 unless your doctor helps you set a different target.

 empty checkbox My blood pressure now is _________.
 empty checkbox My target blood pressure is _________.
 empty checkbox Steps to take:
 
 
Your medicines
  • Talk about any problems you have had with your medicines.
  • Ask if you should take a low-dose aspirin every day to lower your chance of getting heart disease.

 empty checkbox Shared medicine problems?
 empty checkbox Take aspirin?
    Yes____
    No____
 empty checkbox Steps to take:
 
 
Your feet
  • Ask to have your feet checked for problems.
  • Talk about any problems you are having with your feet, such as numbness, tingling, or sores that heal slowly.

 empty checkbox Checked feet?
 empty checkbox Shared problems?
 empty checkbox Steps to help with my feet:
 
 
Your physical activity plan
  • Talk about how often you are physically active, the type of physical activity you do, and any problems you have when being physically active.

 empty checkbox Shared activities?
 empty checkbox Steps to take:
 
 
Your healthy eating plan
  • Talk about what you eat, how much you eat, and when you eat.

 empty checkbox Shared eating habits?
 empty checkbox Steps to take:
 
 
Your feelings
  • If you feel stressed, ask about ways to cope
  • Talk about whether you are feeling sad.

 empty checkbox Shared stress and problems?
 empty checkbox Steps to take:
 
 
Your smoking
  • If you smoke, ask for help with quitting.

 empty checkbox Shared smoking habits?
 empty checkbox Steps to take:
 
 

PDF Version (50 KB) *

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This chart lists important tests, exams, and vaccines to get at least once or twice a year.


Tests, Exams, and Vaccines to Get at Least Once or Twice a Year




Test
 

Instructions
 

Results or Dates
 
A1C test
  • Have this blood test at least twice a year. Your result will tell you what your average blood glucose level was for the past 2 to 3 months.

 Date: __________
 
 A1C: __________
 
 Next test: __________
 
 Blood lipid (fats) lab tests
  • Get a blood test to check your
    • total cholesterol—aim for below 200
    • LDL, or bad, cholesterol—aim for below 100
    • HDL, or good, cholesterol—men: aim for above 40; women: aim for above 50
    • triglyceridesaim for below 150

 Date: __________
 
 Total cholesterol: __________
 
 LDL: __________
 
 HDL: __________
 
 Triglycerides: __________
 
 Next test: __________
 
 Kidney function tests 
  • Once a year, get a urine test to check for protein.
  • At least once a year, get a blood test to check for creatinine.

 Date: __________
 
 Urine protein: __________
 
 Creatinine: __________
 
 Next test: __________
 
Dilated eye exam
  • See an eye doctor once a year for a complete eye exam that includes using drops in your eyes to dilate your pupils.
  • If you are pregnant, have a complete eye exam in your first 3 months of pregnancy. Have another complete eye exam 1 year after your baby is born.

 Date: __________
 
 Result: __________
 
 Next test: __________ 
 
Dental exam
  • See your dentist twice a year for a cleaning and checkup.

 Date: __________
 
 Result: __________
 
 Next test: __________
 

Pneumonia vaccine (recommended by the Centers for Disease Control and Prevention [CDC])
 
  • Get the vaccine if you are younger than 64.
  • If you’re older than 64 and your shot was more than 5 years ago, get another vaccine.
 Date received: __________

Flu vaccine (recommended by the CDC)
 
  • Get a flu shot each year.

 Date received: __________ 
 
Hepatitis B vaccine (recommended by the CDC)
  • Get this vaccine if you are age 19 to 59 and have not had this vaccine.
  • Consider getting this vaccine if you are 60 or older and have not had this vaccine.

 Date of 1st dose: __________
 
 Date of 2nd dose: __________
 
 Date of 3rd dose: __________
 

PDF Version (40 KB) *

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Daily Diabetes Record Page                                                                       Week Starting ________________________
 
 Breakfast 
 blood 
 glucose 
 Medicine   Lunch 
 blood 
 glucose 
 Medicine   Dinner 
 blood 
 glucose 
 Medicine   Bedtime 
 blood 
 glucose 
 Medicine   Other 
 blood 
 glucose 
 Notes: (Special events, sick days, exercise) 
Monday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tuesday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Wednesday   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thursday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Friday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Saturday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sunday  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PDF Version (40 KB) *

You can also find a food and activity tracker at www.ndep.nih.gov.

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Page last updated February 12, 2014


The National Diabetes Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

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1 Information Way
Bethesda, MD 20892–3560
Phone: 1–800–860–8747
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: ndic@info.niddk.nih.gov
Internet: www.diabetes.niddk.nih.gov

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