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( Print out this information to be sure you are following up on your diabetes care. Click here for a printer-friendly version of this form.)
Take a copy of the Physicians Pocket Card to your doctor and ask your doctor to review your dicbetes care and treatment plan.
DIABETES MANAGEMENT: Know Your ABCDE's
AT EVERY VISIT
- Weight and blood pressure
- Foot exam
- Discuss self monitoring blood glucose records
- Discuss ALL medications
- Discuss self-management skills
- Discuss dietary needs
- Discuss physical activity
- Discuss smoking cessation
TWICE A YEAR or MORE:
| Check
your A1c |
___________ |
___________ |
| |
Date |
Date |
ANNUALLY (have
a):
| Dialated
Eye Exam |
___________ |
| |
Date |
| Dental
Exam |
___________ |
| |
Date |
| Flu
Shot |
___________ |
| |
Date |
| Diabetes
Education Review |
___________ |
| |
Date |
| Peripheral
nerve test |
___________ |
| |
Date |
| Treadmill
test or EKG |
___________ |
| |
Date |
ASK YOUR
PHYSICIAN TO CHECK:
| Protein
and fat in your blood |
___________ |
| |
Date |
| Protein
in your urine |
___________ |
| |
Date |
|
Diet and Nutrition
