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Pre-Pump Checklist

  1. ___   I have read the pump packet._____
  2. ___   I am competent counting carbohydrate grams._____
  3. ___   I use an insulin-to-carb ratio and correction factor with ease._____
  4. ___   I record blood sugars, insulin doses, carb grams and activity._____
  5. ___   I have successfully completed CGMS and have reviewed results._____
  6. ___   I have attended pump class and passed the pump class test._____
  7. ___   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.
  8. ___   I have chosen the _____(brand/model) pump.
  9. ___   I will be getting my pump from _____(supplier).
  10. ___   I will be using the _____(infusion set) with ______(length tubing).
  11. ___   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_____

(Patient) ____________________________________



Date ____________