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Medical Management Plan

Diabetes Medical Management Plan (To Be Completed With the Doctor)

Patient Details

Name:

Date of Birth:

Diabetes Diagnosis:

Impaired Glucose Intolerance

Type 1

Type 2

Date Plan Written:

Plan Details

Call the Doctor when:

Call an Ambulance when:

Blood Glucose Monitoring

The low blood glucose level (hypo) range:

mmol/L

The ideal blood glucose level range:

mmol/L

The high blood glucose level range:

mmol/L

Hypoglycemia

Is the person at risk?

Yes

No

Usual symptoms are:

Treatment:

High Blood Glucose Levels

Is the person at risk?

Yes

No

Usual symptoms are:

Treatment:

List the diabetes items that the person needs to carry with them when they leave their home:

Blood Glucose Tests

Does the Person have blood glucose tests:

Yes

No

Blood Glucose Level Test Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Note the Specific Times for Blood Glucose Testing

Before Breakfast

After Breakfast

Before Lunch

After Lunch

Before Dinner

After Dinner

Before Supper

Blood Glucose Test Procedure

Person can do their own blood glucose testing without supervision

Person requires some support to do the test

Person requires total support

Other

Support required is:

Insulin Injections

Days to take Insulin

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Note the Specific Times for Insulin Injecting

Before Breakfast

After Breakfast

Before Lunch

After Lunch

Before Dinner

After Dinner

Before Supper

Insulin Test Procedure

Person can give own injection

Person requires support to give own injection

A qualified nurse gives the insulin injection

Other - more information:

Diabetes Medication

Taking of Medication

Person can take own medication

Person requires support to take medication

A qualified person administers the medication

Other - more information:

Medication	Dosage	Time of Medication			Possible Side Effects of Medication
Medication	Dosage	Breakfast	Lunch	Supper	Possible Side Effects of Medication

What action should be taken if the person refuses medication?

What action should be taken if the person is not eating?

Instructions for buying over the counter medication:

Other Prescribed Medications

Medication	Dosage	Time of Medication			Possible Side Effects of Medication
Medication	Dosage	Breakfast	Lunch	Supper	Possible Side Effects of Medication

Exercise

Preferred Exercise:

How often and how long?

Signs and symptoms to STOP exercising?

Times to test blood glucose:

Blood glucose levels for exercise:

mmol/L

How often to drink water:

When to eat:

Types of food to eat:

Meals

It is recommended that the person have their meals at the same time each day

Meal

Time

Breakfast

Morning Tea

Lunch

Afternoon Tea

Dinner

Supper

How strictly should the healthy eating plan be adhered to?

What action should be taken if the person does not follow the healthy eating plan?

What to do on Sick Days

i.e. Colds, coughs, sore throats, vomiting, diarrhea, injuries

Person

Action to Take

Is rejecting very small quantities of food

Is rejecting all drinks

Is eating only small amounts of food

is rejecting all food

Is vomiting

Has diarrhea

Has a high temperature

Is refusing to have diabetes medication

Is refusing to have insulin

Identify how often and when blood glucose levels should be tested:

Identify when the doctor needs to be contacted:

Indicators of Diabetes Complications Requiring Medical Attention

Nerve damage: Numbness, tingling, shooting pain or burning pain
Kidneys: Urinary tract infections
Eyes: Blurred vision or flashes of light or pain
Feet: Redness, corns, calluses, cuts and sores
Other: Ulcers, sores that don't heal

Diabetes Health Care Team

Doctor

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Diabetes Educator

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Dietician

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Podiatrist

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Eye Specialist

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Other

Name

Address

Phone

Fax

Email

Time Between Visits

Next Appointment Date

Notes

Emergency Contact

Name

Relationship

Address

Phone

Please contact the above person in the following situations:

Diabetes and medication review dates:

Signature - Owner of Medical Management Plan

Signature - Doctor