Free Personal Diabetes Care Record, DPH 9357 - Wisconsin


File Size: 59.5 kB
Pages: 2
Date: September 25, 2001
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS/DPH/BCDPHP
Word Count: 321 Words, 2,117 Characters
Page Size: 270 x 720 pts
URL

http://dhs.wisconsin.gov/forms/DPH/dph09357.pdf

Download Personal Diabetes Care Record, DPH 9357 ( 59.5 kB)


Preview Personal Diabetes Care Record, DPH 9357
Essential Diabetes Mellitus Care Guidelines
Listed below are guidelines for good diabetes care. Show this card to your health care providers at every visit. Ask them to explain what the results mean and to set goals with you. Write down your goals and the dates and results of each test below. Tests (how often) Long term blood glucose (HbA1c) (every 3-6 months) Review daily blood glucose records (each visit) Urine test (yearly) (Microalbumin) Blood Fats (yearly) good cholesterol (HDL)
bad cholesterol

my goal

dates & results of each test/service

(LDL)
triglycerides

Blood Pressure (each visit) Weight / BMI (each visit) Dilated eye exam (with drops) (yearly) Oral health exam (every visit) Dental Visit (every 6-12 months) Foot exam (each visit) Foot risk test (yearly) (Monofilament) Dietician visit (as needed) Diabetes education visit (as needed) Flu shot (yearly) Pneumonia shot (usually once) Talk about the following items regularly with your health care provider: Smoking Medications Physical activity Foot care Nutrition Sick days Stress Low blood sugar High blood sugar Weight Complications Skin care Pregnancy plans Prenatal care Oral health

Personal Diabetes Care Record
Name: Diabetes Care Providers:

Medication(s):

Diabetes Control is Prevention
Taking control of your diabetes can make you feel better and stay healthy. Recent studies have shown that good blood sugar control is important to help prevent or delay serious problems with the eyes, kidneys, nerves and heart. Diabetes is serious yet controllable. All people with diabetes need to know how to take care of themselves. Work closely with your health care team to understand your management plan and to control your diabetes. Remember. Diabetes is serious but controllable. For more information about diabetes, call

1-800-860-8747

This record is based on the 2001 Essential Diabetes Mellitus Care Guidelines developed by the Wisconsin Diabetes Advisory Group and the Wisconsin Diabetes Control Program. Department of Health and Family Services, Division of Public Health DPH 9357 (Rev. 05/01)