BLOOD SUGAR MONITORING LOG

(Gestational Diabetes)



* Date:

* Act #


* Patient’s Name:

* Weeks Pregnant:

* Due date:

* Contact Phone:


To be filled out by patient:

Date

(60-90)
Before Breakfast

(<120) 2hr After Breakfast

(<120) 2hr After Lunch

(<120) 2hr After Dinner

Ketones Results (to be tested daily)


To be Completed by Office:

Reviewed by:

Physician Follow Up:

Yes

No

Physician Signature:

Initiation / Change of Insulin Dosage (to be completed by physician)

Date Ordered:


Type of Insulin

Dosage Before
Breakfast

Dosage Before
Lunch

Dosage Before
Dinner

Dosage Before
Bed Time

Other

NPH

Novolog / Humalog

Other

Logged In

Reviewed

Patient Contacted

Scanned


MUST BE FAXED EVERY SUNDAY:
(305)894-0752 / DIABETES@SFPM.US