Diabetes Health Records

Diabetes Health Records


 

How often Question Answer
Every day How much do you weigh today? _____pounds
Every evening How much liquid did you drink today? _____glasses
Every morning and every evening What is your temperature? _____ a.m.
_____ p.m.
Every 4 hours or before every meal How much insulin did you take? Time | Dose
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 hours What is your blood glucose level? Time | Blood
—— glucose
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 hours
or each time
you pass urine
What are your urine ketones? Time | Ketones
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
Every 4 to 6 hours How are you breathing? Time | Condition
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______
_____ _______


Reminders for Sick Days top

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.


Tests and Goals for Each Visit topThings to Do at Each Visit with Your Health Care Provider

  • Bring your blood glucose logbook and go over the readings with your provider.
  • Get an A1C test (about every 6 months if you don’t take insulin, about every 3 months if you take insulin). Write down the result and set a target goal for your next test.
  • 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.

Have your health care provider do these tests and set goals with you. Record dates and the results in the boxes below.

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
Tests and Goals Dates and Results
         
Blood Glucose (mg/dL)          
A1c
Test/Goal (%)
         
         
Weight/Goal
(pounds)
         
         
Blood Pressure
(goal: __/__mm Hg)
         
Foot Check          

Yearly Tests and Goals topThings to Do At Least Once a Year

  • Get a flu shot once a year, during cold & flu season.
  • Get a pneumonia shot.
  • Have a dilated-eye exam at least once a year.
  • Schedule a foot exam.
  • Have your kidneys tested.
  • Have microalbumin urine test.
  • Have blood fats checked for
    • Overall cholesterol level
    • High Density Lipoprotein or HDL level
    • Low Density Lipoprotein or LDL level
    • Triglycerides
  • Have a dental exam.
  • 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 ______________________

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.

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 orMicroalbumin (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    
Tests and Other Services Dates and Results
Flu Shot          
Urine Protein or Microalbumin (mg)          
Urine Protein orMicroalbumin (mg)          
Total Cholesterol (mg/dL)          
HDL Cholesterol (mg/dL)          
LDL Cholesterol (mg/dL)          
Triglycerides (mg/dL)          
Tobacco Use          
Eye Exam (dilated)          
Foot Exam          

Glucose Log Sheets topGlucose Log Sheet for People Who Do Not Use InsulinUse 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

  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 _______________

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

Glucose Log Sheet for People Who Use InsulinUse 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

  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 __________

  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                        
           

Your Health Care Team top

Primary Doctor or Health Care Provider

Name: __________________________________________

Telephone: ________________________________

Questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Eye Doctor (Ophthalmologist, Optometrist)

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Foot Doctor (Podiatrist)

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: _____________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________
__________________________________________________

__________________________________________________

Dentist

Name: ____________________________________________

Telephone number: ___________________________________

Your questions: ______________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: ____________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Dietitian

Name: __________________________________________

Telephone: ________________________________

Questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Diabetes Educator

Name: __________________________________________

Telephone: ________________________________

Questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Counselor

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Other

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

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