Empire Weekly Blood Glucose Chart
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1Member Services: 1-800-300-8181 (TTY 711)
Weekly blood glucose chart
Name: _____________________________________________
Empire BlueCross BlueShield HealthPlus is the trade name of
Physician’s name: ___________________________________
HealthPlus, LLC, an independent licensee of the Blue Cross
Medication types: ____________________________________
and Blue Shield Association.
Normal results for blood glucose readings
Notes about day:
After
Date
After lunch
After dinner
Other
Insulin/medication
(Skipped meals, exercise, food
breakfast
intake)
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
Time:
Time:
Time:
Time:
Time:
Glucose:
Glucose:
Glucose:
Glucose:
Glucose:
NY-DMWP WBGC-1015 CMAP 4318-15B
Time:
Time:
Time:
Time:
Time:
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