Personal Diabetes Care Plan - North Somerset PCT

Useful information
Local Support Groups
For people with diabetes who would like support and
information from others in the same position, the details
of the local voluntary support groups are;
Weston-super-Mare ‘First Thursday Group’;
Chris Staff 01934 628985
Nailsea, Backwell and District Diabetic Support Group
www.nbdsg.wordpress.com
Portishead Diabetes Support Group
Joy Forbes, Practice Nurse, Portishead Medical Group
08444 773283
Go4Life North Somerset
If you want to become more
active then Go4Life is for you,
helping you to become fitter and
healthier and feel better about
yourself. Local activities include
health walks, yoga and cycling.
For further information please
visit;
www.n-somerset.gov.uk/Leisure/
Go4Life
Personal Diabetes
Care Plan
Please keep this care plan safe
Remember to take it with you to your appointments
Keep it up to date
Personal Information
Name:_____________________________________
NHS Number:_______________________________
GP and Practice:_____________________________
Type of diabetes:_____________________________
If you would like to discuss anything in relation to your
diabetes contact:_____________________________
On:________________________________________
Insulin information (please also carry your insulin card)
Please record information about any current insulin products.
Provide as much detail so that your insulin is clearly identified.
A healthcare professional can help you with this. If someone
else has added information, ask them to sign it.
Date
started
Date
Stopped
Insulin
brand
name
Presentation (for
example vial,
cartridge, or
prefilled pen)
Signature
North Somerset
Diabetes Network
If you need this document
in a different format
please telephone 01275 546753

Other Medication
Please record all the medication you take (apart from insulin on
page 1) and keep this record up to date
Name of
medication
Time to be
taken
Dose
Other
information
•Low density cholesterol (LDL) increases your risk of
cholesterol build up in your arteries.
•High density cholesterol (HDL) helps protect against heart
disease.
•Triglycerides are a measure of the fat circulating in your blood
6.5 7.0 7.5 8.0 8.5 9.0 9.5 10+
Blood glucose
48 53 59 64 70 75 81 86
HbA1c
Mmol/mol - new values with effect from 2011
Fasting blood glucose
HbA1c gives an indication of your blood glucose control over
the previous 2-3 months
5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0+
Fasting blood glucose gives an indication of your blood
glucose control at the time you take the test
The recommended target ranges for non-fasting blood glucose
levels; Before meal: 4-7 mmol
Two hours after meal: less than 8.5 mmol
Foot check results
Skin
condition
Deformity
Sensation
Pulses
Right foot
result and
date
Left foot
result and
date
Right foot
result and
date
Left foot
result and
date
Foot checks
Pulses: - As a general rule if the pulses in your feet are felt
then the circulation to your feet is ok.
Skin condition: - Dry skin is not as healthy or strong as
supple skin and tends not to withstand the rubbing, knocks and
bumps feet often receive.
Deformity: - feet that have an unusual shape or deformity tend
to be at increased risk of problems developing from shoes or
other toes rubbing and causing sores.
Sensation:- Diabetes can affect how well the nerves in your
feet work. If they are not working properly this can cause
strange feelings in your feet or no feeling at all. If you have
little or no feeling in your feet you may not be aware when they
are being damaged e.g. blisters forming or being rubbed.

What do the results mean?
Body Mass 22 23 24 25 26 27 28 29 30+
Index
Waist Circumference
Male
Female
•Body Mass Index (BMI) is a measure of body fatness.
•Waist circumference is a measure of the central body fat or
•central obesity.
•High BMI and Waist circumference can contribute to heart
disease, high blood pressure and stroke. It can also worsen
diabetes control.
Blood Pressure (BP)
BP Systolic 125 130 135 140 145 150 155 160 165+
BP Diastolic
65 70 75 80 85 90 95 100 110+
• Blood pressure tells you how hard your heart has to work to
move blood around the body.
• Having high blood pressure can increase your risk of
developing heart disease, stroke and kidney disease.
Blood fats
Total cholesterol
88cms /
34.5ins
2 3 4 5 6 7 8+
Results
Please record your results to monitor your progress
Weight
Body Mass Index
(BMI)
Waist
Measurement
Blood
Pressure
Total
Cholesterol
LDL
Cholesterol
HDL
Cholesterol
Triglycerides
Date &
Result
Date &
Result
Date &
Result
Date &
Result
Date &
Result
LDL Cholesterol
HDL Cholesterol
1 2 3 4 5 6+
0.5 1.0 1.5 2.0 2.5+
HbA1c
Triglycerides
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0+
• Total cholesterol measures all the cholesterol in your blood
and can increase your risk of heart disease and stroke.
Diabetic
Retinopathy
Screening
(annual)

Personal action plan
Please complete this plan, with support from your
healthcare professional, remember to include dates.
Blood glucose targets
Areas / concerns identified for change;
Goals / targets
Plans for
action
Target date for
achievement and
review dates