Vanderbilt Diabetes Program Blood Glucose Record
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1Vanderbilt Diabetes Program Blood Glucose Record
Patient Name:
Patient Phone Number: (
)
or
Email Address:
Deliver this Fax to:
at
Fax Number:
Week of:
____/____/_____
Blood Glucose Test Results, Insulin Doses, and Grams of Carbohydrates
Day/Date
Breakfast
Lunch
Dinner
Bedtime
Other
Before After
insulin Carbs Before After Insulin Carbs Before
After
Insulin Carbs Before
Insulin
Carbs
Average
Blood
Sugar
*Notes: Record Illness, Low Blood Sugar, Exercise, Large Meal, Emotional Stress, etc…
Target A1c_____
Target pre meal blood ssugar__Target post meal blood sugar___ Insulin/bcarb ratio o___________________
_____________________
_______________________
_Target carbs______________________
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Parent category: Medical