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Date:
___________________________
My
Action Plan to Control My Blood Sugar
Three
questions about my blood sugar control to ask my health care
provider:
What is my A1c
goal? _______
What
schedule of BGM will tell me the most about my daily control?
1.
__________________________________________________
2.
___________________________________________________
3.
___________________________________________________
What
is my blood sugar goal before meals when self-testing using
a
blood glucose meter? _______
What is my
blood sugar goal 2 hrs after meals when self-testing using
a
blood glucose meter? _______
What is my
blood sugar goal at bedtime when self-testing using a
blood glucose meter? _______
Three
things I will work on over the next three months to control my
blood sugar:
1.
___________________________________________________
2.
___________________________________________________
3.
___________________________________________________
Note: Select things that you really
want to do. Here are two examples:
1. I will walk briskly around my neighborhood with a friend for
20 minutes every Monday, Wednesday, and Friday at 5:00 p.m.
2. I will eat the three vegetables included in my daily meal
plan.
My
three main reasons to keep my blood sugar in a good range:
1.
___________________________________________________
2.
___________________________________________________
3.
___________________________________________________
Note:
Your goals will change over time, so be ready to change your
current plan or write out a new one at least every three months.
Then place your action plan where you will see it often.
Do it today!
Signed:________________________________________________________
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