Blood Sugar Log Report
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1IT IS VERY IMPORTANT FOR PATIENTS TO COMPLETE THIS SECTION
EVERY TIME YOU SEND IN A BLOOD SUGAR LOG REPORT
WHAT IS YOUR USUAL INSULIN REGIMEN
DO YOU USE A SLIDING SCALE?
DO YOU TAKE PILLS FOR YOUR DIABETES
(Correction factor)
How and when do you
Insulin Name & Dose
When
:
Name & Dose
Name of Insulin Used
take it
Sliding scale formula for blood sugars greater than _________
Morning
take blood sugar minus 100 divided by _______ = insulin units
Evening
Meals
IF YOU USE AN INSULIN PUMP WHAT ARE YOUR PUMP SETTINGS
TIME
BASAL RATE
Apidra= A
Lantus= L
Levemir= LV
Humalog= H
Novolog=N
NPH= NP
Humulin= HL
Novolin= NL
Humalog 70/30= H7
Humulin 70/30= HL7
Novolog 70/30= N7
Novolin 70/30= NL7
BLOOD SUGAR READINGS AND INSULIN DOSES
BREAFAST
LUNCH
DINNER
BEDTIME
2 AM
DATE
Pre
Dose
Post
Dose
Pre
Dose
Post
Dose
Pre
Dose
Post
Dose
BS
Dose
BS
Dose
Meal
Meal
Meal
Meal
Meal
Meal
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
SSI
SSI
SSI
SSI
SSI
SSI
SSI
SSI
Blood Glucose Log Sheet
Patient’s Name:
Date of Birth:
Fax to 770-979-7455
Contact Phone #:
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