THE MOST IMPORTANT PERSON TO MANAGE YOUR DIABETES. We at Rural Health, Inc. ( Note: Diabetes is a very serious disease that can damage the blood vessels and …
DIABETES REPORT CARD
Patient:
QUESTIONS TO ASK AT MY
NEXT VISIT:
| | Date| Date| Date|
| | | | |
| | | | |
| | | | |
|Weight | | | |
|Blood Pressure | | | |
|Goal - 130/80 | | | |
|HgA1C | | | |
|Goal less than 7 | | | |
|Cholesterol | | | |
|Goal less than 200 | | | |
|HDL good cholesterol| | | |
| | | | |
|Goal higher than: | | | |
|Men - 40, women - 45 | | | |
|LDL bad cholesterol | | | |
|Goal less than 100 | | | |
YOU ARE THE MOST IMPORTANT PERSON TO MANAGE YOUR DIABETES We at Rural
Health, Inc will guide you and offer support to you
On the reverse side are things that you can
do to help gain and maintain
control of your diabetes and to prevent complications related to diabetes
Note: Diabetes is a very serious disease that can damage the blood
vessels and nerves leading to the brain, eyes, kidneys, toes and feet
DIABETES SELF-MANAGEMENT
|Accomplished| | |New |Ongoing|Comments |
| | | |Goal | | |
| | | | |goal | |
| |I will keep my | | | | |
| |appointments and | | | | |
| |work hard to keep | | | | |
| |my | | | | |
| |HgA1c less than | | | | |
| |70 | | | | |
| | | | | | |
| |I will exercise | | | | |
| |________ minutes | | | | |
| |_______days per | | | |
|
| |week | | | | |
| |I will check my | | | | |
| |feet daily If I | | | | |
| |see a sore or an | | | | |
| |irritation, I will| | | | |
| |see my provider | | | | |
| |I will see the | | | | |
| |podiatrist once a | | | | |
| |year | | | | |
| |I will follow my | | | | |
| |diet I will see | | | | |
| |the dietician or | | | | |
| |diabetic nurse for| | | | |
| |diet | | | | |
| |instruction/review| | | | |
| |I will try to | | | | |
| |obtain my ideal | | | | |
|
|body weight I | | | | |
| |will try to lose | | | | |
| |______ lbs by my | | | | |
| |next visit | | | | |
| |I will take my | | | | |
| |medications every | | | | |
| |day as prescribed,| | | | |
| |including a baby | | | | |
| |aspirin daily | | | | |
| |I will stop | | | | |
| |smoking I will | | | | |
| |see a smoking | | | | |
| |cessation | | | | |
| |counselor | | | | |
| |I will see the eye| | | | |
| |specialist every | | | | |
| |year or as | | | | |
|
|recommended | | | | |
| |I will take my | | | | |
| |blood sugar as | | | | |
| |instructed | | | | |
| |I will see the | | | | |
| |dentist every year| | | | |
| |or as recommended | | | | |
Patient signature: Date:
lab
