<p>My Diabetes Care Plan</p><p>My Diabetes Care Plan aims to:</p><p> Help you manage your health and care as well as possible </p><p> Helps you and the medical professionals, i.e. doctors and nurses, and others who may be involved with your care to work together with you to know about your health condition(s) and what is important to you.</p><p> Provide information about your condition, your medication and your preferences in a convenient form which can be available should you need to visit a hospital or a surgery other than your usual one (e.g. who do not have access to your GP notes)</p><p> Help everyone involved in your health to know what your goals are over the next 12 months.</p><p>Created:</p><p>Printed</p><p>1</p><p>About Me: My Name: What I like to be called: Address: DOB:</p><p>Who lives at home: Work: (Circle one ) I am working full time / part time / unemployed / sick leave / retired</p><p>Contact Details: Preferred means Communicatio Phone: of contact: n needs: Mobile: Email: </p><p>Religion Ethnic My preferred Background: language is: My NHS GP Name, number: Address , Tele number My next of kin and other contacts: Name Relationship to me Contact details Next of kin:</p><p>My main carer/supporter and others involved in my care (if appropriate): Name Relationship to me Contact details Main carer/supporter: This is the care my carer provides to me:</p><p>These are the e.g. Carer’s in Herts or Crossroads services my carer accesses for support</p><p>2</p><p>What is important to me? Consider diet, exercise, lifestyle & wellness goals</p><p>Family/ Carer Views:</p><p>3</p><p>My Medication</p><p>(You may wish to attach a list of your current medications to this care plan. Please ask your pharmacist or GP to provide you with a recent copy).</p><p>Medication Dose Format eg. I take this I take this medicine because tablet, syrup, medication at it will ( eg. help prevent me injection / type the following from having a heart attack) of device etc times</p><p>4</p><p>My allergies and drug reactions are: Drug Name Reaction (e.g. rash or diarrhoea)</p><p>This is the support I need with managing my medicines:</p><p>Concerns I have about my medication that I want to discuss with my doctor:</p><p>Date of last review: Date of next review:</p><p>Contact details for pharmacist: Name:</p><p>Location: Phone Number:</p><p>5</p><p>Monitoring My Diabetes: </p><p>My HbA1c Date HbA1C Result</p><p>Diabetes Current Levels & Targets 1 Blood Glucose Pre-Meal Current: Target: 2 Blood Glucose – 2hrs post meal Current: Target: 3 HbA1c Current: Target: 4 Blood Pressure Current: Target: 5 Cholesterol Non-HDL Current: Target: 6 BMI Current: Target: </p><p>Annual Check 1 Blood test for glucose (HbA1c) 2 Blood pressure checked 3 Blood test for cholesterol (LDL) 4 Eyes screened (retinopathy) 5 Feet checked 6 Blood test for kidneys 7 Urine (ACR) test for kidneys 8 Weight and BMI 9 Smoking Support 10 Alcohol Intake 11 Education Course</p><p>6</p><p>Monitoring My Diabetes</p><p>Lifestyle Weight Your current: Your target: Ideal: BMI: _____ BMI: _____ BMI <25 Waist: _____ cm Waist: _____ cm Men waist ≤94 cm Women waist ≤80 cm Physical Activity Your current: Your target: Ideal: At least 30 minutes of walking (or equivalent) on 5 or more days per week (Minimum of 150 minutes per week)</p><p>Smoking Current status: Target: Complete cessation Avoidance of second- hand smoke Number per day:</p><p>Alcohol Your current: Your target: Ideal: Number of standard standard drinks on any ≤2 standard drinks on drinks on any day day any day</p><p>Biomedical Cholesterol / Lipids Your current: Your target: Cholesterol _____ Cholesterol _____ mmol/L mmol/L Triglycerides _____ Triglycerides _____ mmol/L mmol/L LDL-C _____ mmol/L LDL-C _____ mmol/L HDL-C _____ mmol/L HDL-C _____ mmol/L</p><p>Blood pressure Your current: < _____ Your target: < _____ Ideal: <130/80 mmHg For people with proteinuria >1g/day (with or without diabetes) <125/75 mmHg</p><p>Blood Sugar Your current: Your target: </p><p>___BM (fasting) ___BM (fasting) ___ BM (random) ___ BM (random)</p><p>7</p><p>Questions I want to ask my health professional at my next appointment and other relevant information: </p><p>8 My Next Steps / Personal goals </p><p>List the key issues, goals and steps you have identified to improve your health over the next 12 months </p><p>Date Issues Identified Goals and Action Steps ( what & how) By who Complete</p><p>9 This shared care plan was created by me/ in partnership with me (*delete as appropriate ) and reflects my personal information, wishes, needs and goals. </p><p>Completed By:</p><p>Signature:</p><p>Date:</p><p>Additional Information </p><p>For further Information on a range of other support services I can contact Herts Help on 0300 123 4044 (Mon – Friday 8am-6pm) http://www.hertsdirect.org/your-community/ihertshelp/</p><p>NHS Choices: good place to start when looking for trusted health information. http://www.nhs.uk/pages/home.aspx</p><p>10</p>