Print this page out and fill in this record about your diabetes medicines with the help of your doctor or diabetes teacher. Write this in pencil so you can make changes when your doctor makes changes in your diabetes medicines.
- The names of the diabetes medicines (insulin or pills) I take are
Name(s) of diabetes medicine:____________________________________________
____________________________________________ - I take _________________ (name of diabetes medicine) _____ times a day.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________. - I take _________________ (name of diabetes medicine) _____ times a day.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________. - I take _________________ (name of diabetes medicine) _____ times a day.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________.
At (time)__________ I take (amount)_______________. - I should call my doctor or diabetes teacher if I have these problems with my diabetes medicines:
____________________________________________
____________________________________________ - I should call my doctor or diabetes teacher if my blood sugar is too low or too high for several days.
Too low is _______ mg/dl for _______ days.
Too high is _______ mg/dl for _______ days. - My blood sugar should be between _________mg/dl and _________mg/dl before my first meal of the day.
- My blood sugar should be between _________mg/dl and _________mg/dl 1 to 2 hours after a meal.
- My blood sugar is too low at ________________________mg/dl.
- My blood sugar is too high at ________________________mg/dl.
- My hemoglobin A1c should be ________________________%.
