Question 1

My prescription, in one place.

Accepted Answer

**Date checked with my pharmacist:** ____________________ **Exact presentation and strength on the box:** ____________________ **My prescribed dose and schedule:** ____________________ **Number of prescribed doses in this exact pen or vial:** ____________________ **Storage and discard rule after first use:** ____________________ **First-use date / discard date:** ____________________ **What to do after a longer interruption:** ____________________ **Pharmacy contact / prescriber contact:** ____________________ Recheck this page whenever the product, device, strength, or instructions change. Do not use a previous pen’s information automatically.

Question 2

My food and fluid plan.

Accepted Answer

**My main health and daily-life goals:** ____________________ **Fluid advice, including any restriction:** ____________________ **Carbohydrate or other individual targets:** ____________________ **Food allergies and relevant intolerances:** ____________________ **Two breakfasts I can repeat:** ____________________ **Two lunches I can take with me:** ____________________ **Two dinners I can make when tired:** ____________________ **One shelf-stable backup / one freezer backup:** ____________________ **What I will do if I cannot eat or drink adequately:** ____________________

Question 3

A three-day food and symptom record.

Accepted Answer

Record an ordinary day, not a demonstration of what you think you should eat. Copy this page for three days if useful. **Date / medicine and last dose:** ____________________ **Bowel changes / vomiting or diarrhea / fluids tolerated:** ____________________ **Glucose or blood pressure, only if part of my monitoring plan:** ____________________ **What I want to ask about:** ____________________

Question 4

My low-blood-sugar plan.

Accepted Answer

Complete this with your diabetes team if you are at risk of lows. The general response is in Chapter 3; individual instructions take priority. **Medicines that affect my risk:** ____________________ **When and how to check:** ____________________ **My measured fast-acting carbohydrate treatment:** ____________________ **Where I carry it / where a backup is kept:** ____________________ **My prescribed glucagon, if any, and its location:** ____________________ **Person who knows how to help:** ____________________ **When to contact my team / when to call 911:** ____________________ Never give food or drink by mouth to someone who cannot swallow safely.

Question 5

My strength session.

Accepted Answer

**Date / Track A or B / how I feel before starting:** ____________________ **Any symptoms or movement that needs advice:** ____________________ **Next session: repeat, simplify, or make one small progression:** ____________________

Question 6

My weekly review.

Accepted Answer

**A meal that worked well:** ____________________ **A situation that made food difficult:** ____________________ **Strength sessions completed / movement I enjoyed:** ____________________ **An everyday task that feels easier or harder:** ____________________ **Weight trend, if monitoring is helpful:** ____________________ **Symptoms I need to discuss:** ____________________ **One practical change for next week:** ____________________ **What I will keep exactly as it is:** ____________________

Question 7

If my treatment changes.

Accepted Answer

**Why we are considering a change:** ____________________ **The prescription plan agreed with my clinician:** ____________________ **Food and activity routines I can maintain:** ____________________ **What we will monitor and how often:** ____________________ **What change should prompt contact:** ____________________ **The next appointment, arranged before the change:** ____________________

I want pages I can print and carry