Accu Chek 360 View Self Mgmt Form

AC 360 View Form.qxd 25.10.2007 15:17 Uhr Seite 1PATIENT NAMEINSULIN NAMEDOSE (UNITS)SHOTS/DAYORAL DIABETES MEDICATIONSDOSETIMES/DAYPHYSICIAN NAMEPATIENT PHONEPHYSICIAN PHONEACCU-CHEK 360° View blood glucose analysis systemDay 1 Date Day 2 Date Day 3 Date ast ast e e e e ast ast e e e e ast ast e e e e ororororororororororororeakfeakfeakfeakfeakfeakfBefbr2 hours after brBeflunch 2 hours after lunch Befdinner 2 hours after dinner Befbed Befbr2 hours after brBeflunch 2 hours after lunch Befdinner 2 hours after dinner Befbed Befbr2 hours after brBeflunch 2 hours after lunch Befdinner 2 hours after dinner Befbed Time Meal Size S M L —S M L—S M L—S M L——S M L—S M L—S M L——S M L—S M L—S M L—Energy Level* 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5Blood Glucose >300 mg/dL 261-300Emg/dLNG221-260mg/dL RA181-220mg/dLAfter 141-180Meal UCOSEmg/dLGoal L111-140 Gmg/dL**81-110OODmg/dL**LB51-80Fasting/ mg/dLBefore Meal <50Goal mg/dLWhat did you learn from doing this analysis of your blood glucose results?*ENERGY LEVEL What is 1 2 3 4 5 your energy Very Low Somewhat Moderate Somewhat Very High level? Low High WARNING: Do not adjust your prescribed oral medication Bring this form and your ACCU-CHEK blood glucose monitoring systemor insulin therapy without first consulting your physician. to your next physician appointment.** American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. 2002.AC 360 View Form.qxd 25.10.2007 15:18 Uhr Seite 2Instructions to patient:ACCU-CHEK 360° View blood glucose analysis systemComplete this form over 3 consecutive days.Data can show you:Step 1• Trends in blood glucose levelsFill in the dates for the• The relationship between blooddays on which you willglucose values andtrack your blood – Time of dayglucose results.– Meal size– Energy levelStep 2Test your blood ACCU-CHEK 360° View blood glucose analysis systemglucose using yourACCU-CHEK bloodglucose monitoringsystem at the timesindicated to the left.Step 3Enter the time of thetest in the first row ofthe chart.Step 4Based on your normaleating habits, describethis meal size by circlingSmall, Medium or Largein the second row.Step 5Rate your energy levelon a scale of 1 (verylow) to 5 (very high) andcircle that score here.Step 6Enter your bloodglucose value in thefourth row for that day.Step 7Graph your blood** American College of Endocrinology ConsensusBy drawing a line throughOut-of-range blood glucoseglucose level (fromStatement on Guidelines for Glycemic Control. 2002.the recorded results, youvalues can indicate a need forStep 6) by placing an Xcan easily identify trendsbetter blood glucose control,in the correspondingin blood glucose.and might suggest the need torow of the chart. Thenadjust and/or change therapy.connect the Xs. See▲other side for example.this form. instructions for completing as shown to reveal step-by-stepold over the light yellow panel FACCU-CHEK and ACCU-CHEK 360° are trademarks of Roche.Note to patient: 2007 Roche Diagnostics. All rights reserved. 326-36334-0407