My Self-Management Check List

Y / N / NA / Discuss with HCP
Goals and Action Plan
1. I am aware of my last blood pressure reading /  Let’s discuss my numbers
-Top number (systolic) less than 130
-Bottom number (diastolic) less than 80
2. I am aware of my A1C and Average Blood Glucose /  Let’s discuss my numbers
-Less than 7% or ___ (Goal set with HCP)
3. I am aware of my cholesterol numbers /  Let’s discuss my numbers
-LDL (bad) cholesterol less than 100
-HDL (Good) cholesterol less than 40
-Triglycerides less than 150
4. I am aware of my serum creatinine and GFR
values: /  Let’s discuss my numbers
- Serum Creatinine: ______
-GFR greater than 60:______
5. I am thinking about setting a goal to quit smoking /  Let’s discuss my options
6. I am checking my blood glucose at home
 Twice a day or more
 About once a day
 A few times a week
 Once a week
 I don’t own a home glucose meter /  I would like to see a diabetic educator or HCP
7. I am checking my feet for sores and numbness
 Daily or almost every day
 A few times a week
 Once a week
 Twice a month
 Monthly
 Not at all /  Ask HCP to inspect feet
 I would like to see a podiatrist
8. I have seen an eye doctor for a dilated eye exam in
the last year.
9. I have seen a dentist for an exam in the last year.
10. I would like to discuss a flu shot and pneumonia
vaccination
11. I have a medication list to review
 I would like to ask about actions
 I would like to ask about side effects
 I would like to ask about how to take meds
 I have questions about new herbal, supplements, and OTC meds
 Please discuss my meds with my other HCPs
 Other questions______ /  Ask HCP to review meds
Y / N / NA / Discuss with HCP
Goals and Action Plan
12. I am managing my nutrition by:
 Eating ____servings of fruits and vegetables
daily
 Eating a low fat diet
 Using a nutritional supplement______
 Counting carbs for ______carbs per meal
 Other ______ /  I would like to see a diabetic educator, dietician or HCP
 I would like know about nutrition classes
13. I am reading (or whoever buys groceries) the
nutrition facts label on any foods I buy /  I would like to see a diabetic educator, dietician or HCP
14. I am following a prescribed diet
 Low salt/sodium
 Lower protein
 Lower potassium
 Other special diet______ /  I would like to see a diabetic educator, dietician or HCP
15. I am managing and thinking about my emotions
and coping with my chronic illness
I have questions about:
 Feeling emotionally low
 Coping better
 Finding supportive outlets /  I would like to see a diabetic educator, counselor or HCP
16. I am thinking about my social support
 I would like have my ______come to the
next visit to discuss ______
______
17. I am managing and thinking about affording
medications and other concerns
I would like to discuss:
 Medicare Plans
Adding a medication to the drug formulary for my insurance plan
Obtaining generic medications
Low-cost to no-cost medication support from others
Other______ /  I would like to discuss my concerns with social service

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