Patient:_______________ MR #:_______________ Provider:_______________ Date:_______________


Improving Your Diabetes: It’s As Easy As ABC
A ! " #$is is your %average sugar& test' It s$ou(d be (ess t$an )*'
My (ast A ! +as: __________ ,date: __________-

B(ood pressure " B(ood pressure s$ou(d be (o+er t$an ./01/'
My b(ood pressure today +as: __________

C$o(estero( " #$e bad !$o(estero( ,2D2- s$ou(d be (o+er t$an //'
My (ast 2D2 ,bad- !$o(estero( +as: __________ ,date: __________-

Diabeti! 3oot e4am " It is best to $ave your 3eet e4amined o3ten'
#a5e o33 your s$oes and so!5s so +e !an !$e!5 your 3eet6

Eye e4am
My eyes need to be !$e!5ed by an eye do!tor7 at (east on!e a year' My (ast diabetes eye e4am +as: __________

8e+ e4tras:
Aspirin " I3 your do!tor t$in5s it is sa3e 3or you7 p(ease ta5e a baby aspirin every day' I am on an aspirin every day' My do!tor t$in5s t$at I s$ou(d not be on an aspirin' I3 you smo5e7 p(ease7 9#:P 9M:;I<=6 I do not smo5e' My do!tor o33ered to $e(p me >uit smo5ing' Be sure your s$ots are up to date' Pneumonia s$ot is re!ommended at (east on!e' =et a 8(u s$ot every year' Pneumonia s$ot is up to date' 8(u s$ot is up to date' 9e(3?management goa(: :ne t$ing I +ou(d (i5e to do t$is +ee5 to improve my $ea(t$ is: @o+ !on3ident am I t$at I !an do t$isA B . C D E ) 1 F /
<ot !on3ident Gery Con3ident

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