**Record for Sick Days**
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 top

Things 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.

**Each Visit—SAMPLE**
Tests and Goals	Dates and Results
Tests and Goals	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
A1c Test/Goal (%)	8.0	8.0	7.5		7.5
Weight/Goal (pounds)	180	175	172	170	165
Weight/Goal (pounds)	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

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

Tests and Goals for Each Year top

Things to Do At Least Once a Year

Get a flu shot (October to mid-November).
Get a pneumonia shot (if you’ve never had one).
Get a dilated-eye exam.
Get a foot exam (including check of circulation and nerves).
Get a kidney test.
- Have your urine tested for microalbumin.
- Have your blood tested for chemicals that measure your kidney function.
- Get a 24-hour urine test (if your doctor advises).
Get your blood fats checked for
- Total cholesterol.
- High-density lipoprotein (HDL).
- Low-density lipoprotein (LDL).
- Triglycerides.
Get a dental exam (at least twice a year).
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.

**Every Year—SAMPLE**
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

**Every Year**
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 top

Glucose Log Sheet for People Who Do Not Use Insulin

Use 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

**Daily Log—SAMPLE**
	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar	Blood Sugar	Notes
	Breakfast	Lunch	Dinner	Bedtime	Other	Notes
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 _______________

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

Glucose Log Sheet for People Who Use Insulin

Use 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

**Daily Log—SAMPLE**
	Insulin Type	Dose	Blood Sugar	Dose	Blood Sugar	Dose	Blood Sugar	Notes
	Insulin Type	Breakfast		Lunch		Dinner		Notes
Mon	Reg	8	121	3	187	4	118
Mon	NPH	20	121		187		118
Tues	Reg	8	112	2	104	4	115
Tues	NPH	20	112		104		115
Wed	Reg	8	109	3	158	4	161
Wed	NPH	20	109		158		161
Thurs	Reg	8	111	2	114	4	110
Thurs	NPH	20	111		114		110
Fri	Reg	8	102	2	112	3	68	*Didn't eat much lunch – Busy day!
Fri	NPH	20	102		112		68	*Didn't eat much lunch – Busy day!
Sat	Reg	8	124	3	161	4	118
Sat	NPH	20	124		161		118
Sun	Reg	9	*175	2	99	4	110	*Slept late.
Sun	NPH	20	*175		99		110	*Slept late.

Week Starting ___________

**Daily Log**
	Insulin Type	Dose	Dose	Dose	Dose	Dose	Notes
	Insulin Type	Breakfast	Lunch	Dinner	Bedtime	Other	Notes
Mon
Mon
Tues
Tues
Wed
Wed
Thurs
Thurs
Fri
Fri
Sat
Sat
Sun
Sun

Your Health Care Team top

Primary Doctor or Health Care Provider

Name: __________________________________________

Telephone number: ________________________________

Your 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 number: ________________________________

Your questions: ___________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

Diabetes Educator

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

Counselor

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

Other

Name: __________________________________________

Telephone number: ________________________________

Your questions: ___________________________________

__________________________________________________

Important points: __________________________________

__________________________________________________

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Page last modified: December 20, 2005
Content Source: National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes Translation

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Division of Diabetes Translation