Blood Sugar Log
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1Patient Communication; Phone Encounters
NorthEast Peds Endocrinology
Phone: (704) 782-6030
INSULIN PUMP USERS BLOOD SUGAR LOG
**(Please allow 3 business days for replies, or call to speak to nurse if urgent)
Fax: (704) 782-6032
Name:_________________________ DOB:______________ Parent name:__________________ Pump type:________________
Number to contact with recommendations:_________________________ (is this home, work, or fax?___________)
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Date
Bkfst
Lunch
Din
Bed
MN
Other
Basal
NOTES
12 MN___
Time
___ ____
BG/ket.
___ ____
Carbs
___ ____
Site change? Y/N Time:_____
Bolus
Recommendations:
MD Signature:_____________________ Date:________
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