Blood Glucose Log
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1Phone: (919) 876-7692
R
E
A
ALEIGH
NDOCRINE
SSOCIATES
BLOOD GLUCOSE LOG
Attention:
O Becker, MD
O Holt, MD
O Berlin, MD
O Stall, MD
O Weir, MD
O Rand, MD
O Hill, PA-C
O Crowell, NP
Fax to: 919-954-3365
Name:__________________________________________
DOB:___________________
Phone: (_____)_______________
Date: __________________
Glucose Readings
Diabetes Medication Doses
Comments
During
Breakfast
Lunch
Supper
Breakfast
Lunch
Supper
Bedtime
Date
Night
Before
After
Before
After
Before
After
Bedtime
Goals for blood glucose:
Insulin to carbohydrate ratio:
Supplemental insulin for high blood glucose:
Before meals: _____________
Breakfast: _________
(Blood glucose - X) = # units rapid insulin
1 hour after meals: __________
Lunch: ___________
Y
Bedtime: _________________
Supper: ___________
X= Blood glucose goal (see left)
During night: ______________
Snacks: ___________
Y= Sensitivity factor: ________
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Parent category: Medical