Henry Ford Glucose (Blood Sugar) Levels
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1Glucose (Blood Sugar) Levels
SM
Instructions: Record your blood glucose level at meals and bedtime. Record insulin dose if taken. Please bring this chart
to your clinic appointment.
Chart Start Date
Glucose (Blood Sugar) Levels
: ______/______/______
Blood Glucose
Reading
Insulin
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Dose Taken
Breakfast
Lunch
Dinner
Bedtime
Snack
Sliding Scale of Blood Glucose Levels for Insulin Dose:
70 – 140 ___0___ units
141 – 180 ________ units
181 – 220 ________ units
221 – 260 ________ units
261 – 300 ________ units
301 – 340 ________ units
341 – 400 ________ units and Notify Your Doctor Immediately
IMPORTANT: Please have doctor fill in your appropriate insulin dose for each blood glucose level above.
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Parent category: Medical