- ___ I have read the pump packet._____
- ___ I am competent counting carbohydrate grams._____
- ___ I use an insulin-to-carb ratio and correction factor with ease._____
- ___ I record blood sugars, insulin doses, carb grams and activity._____
- ___ I have successfully completed CGMS and have reviewed results._____
- ___ I have attended pump class and passed the pump class test._____
- ___ I have contacted my insurance company; they will cover_____; I will be responsible for ______ of the cost of the pump/supplies. This amounts to $_____ per month.
- ___ I have chosen the _____(brand/model) pump.
- ___ I will be getting my pump from _____(supplier).
- ___ I will be using the _____(infusion set) with ______(length tubing).
- ___ I agree to follow this meal plan for the next 6 weeks so that insulin doses can be adjusted:
breakfast_____gms snack_____ lunch_____ snack_____ supper_____ snack_____