My Action Plan to Control My Blood Sugar

Jun 11, 2004
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Date: ___________________________

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:________________________________________________________