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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:

1.     What is my hemoglobin A1c goal? _______

2.     What is my blood sugar goal before meals when self-testing using
          a  blood glucose meter? _______

3.      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.

The people who can help me do these things (e.g., friend, co-worker, health care provider):

1. ___________________________________________________

2. ___________________________________________________

3. ___________________________________________________

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!

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California Diabetes Foundation
 2275 Huntington Drive, #207
San Marino, CA 91108
 USA
 Email: info@diabetesfoundation.org
 
Disclaimer

*NDEP is a Joint Program of the National Institutes of Health and the Centers for Disease Control and Prevention