Blood Glucose Log Sheet Template
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1Blood Glucose Log Sheet
Please Sign and Date Section A & Complete Section B
A: Patient Information:
Patient Name:
Patient DOB:
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* By signing above, the patient or Authorized Representative certifies that the blood glucose testing information below is complete and accurate.
If patient is unable to sign due to a physical or mental condition, an Authorized Representative of the patient must sign the patient's name and date above
and complete the section below. By signing on behalf of the customer, you acknowledge that you have authority to do so.
By: Authorized Representative's Signature: ________________________________ Authorized Representative's Name: ____________________________
Relationship to Patient: ______________________________ Physical/Mental Reason patient is unable to sign: __________________________________
Address: __________________________________________ City: _____________________________ State: _______________ Zip: _________________
B: Blood Glucose Log:
Day 1 Results
Day 2 Results
Day 3 Results
Day 4 Results
Day 5 Results
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Day 6 Results
Day 7 Results
Day 8 Results
Day 9 Results
Day 10 Results
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Day 11 Results
Day 12 Results
Day 13 Results
Day 14 Results
Day 15 Results
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Day 16 Results
Day 17 Results
Day 18 Results
Day 19 Results
Day 20 Results
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Day 21 Results
Day 22 Results
Day 23 Results
Day 24 Results
Day 25 Results
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Day 26 Results
Day 27 Results
Day 28 Results
Day 29 Results
Day 30 Results
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