Blood Sugar Log printable pdf download

Blood Sugar Log

Maternal F etal M edicine

Call o r f ax b loodsugars t o n urse w eekly a t

8 12-‐485-‐1894 D ate____________

or f ax t o 8 12-‐485-‐1870

Patient N ame_________________________________________ P hone # _____________________

Date

Breakfast

Lunch

Dinner

Bedtime

3am

Sliding s cale

Exercise

Ketones

Fasting / 1 h r

Before / 1 hr

insulin d ose

Mins

-‐

C urrent M ed D ose (

N ew M ed d ose

Physician u se o nly)

B reakfast L unch D inner B edtime B reakfast L unch D inner B edtime

NPH _ _____ _ _____ _ _____ _ _____ N PH _ _____ _ _____ _ _____ _ _____

Humalog/Novolog _ _____ _ _____ _ _____ _ _____ H umalog/Novolog _ _____ _ _____ _ _____ _ _____

Glyburide _ _____ _ _____ _ _____ _ _____ G lyburide _ _____ _ _____ _ _____ _ _____

Metformin _ _____ _ _____ _ _____ _ _____ M etformin _ _____ _ _____ _ _____ _ _____

-‐

Notes

______________________________________________________________________________

Check k etones i n u rine f or b loodsugars g reater t han 1 80

7994-‐ 5 0 1 1/11

Blood Sugar Log