BLOOD SUGAR MONITORING LOG

(Pre-gestational Diabetes)



* Date:

* Act #:


* Patient’s Name:

* Weeks Pregnant:

* Due date:

* Home Phone:

* Work Phone:

* Cell Phone:


To be filled out by patient:

Please indicate how your diabetes is being managed:

Diet only

Oral Medication & Diet

Insulin & Diet


Type of Insulin

Cloudy (NPH) Clear(Humalog/Novolog)

Dosage Before
Breakfast

Dosage Before
Lunch

Dosage Before
Dinner

Dosage Before Bed Time

Other

NPH

Novolog / Humalog

Other


Date

60-90 before Breakfast

(<120) 2 hr After Breakfast

(<105) Before Lunch

<120) 2hr After Lunch

(<105) Before Dinner

<120 2hr After Dinner

<120 Bed Time

Ketones Results
(to be tested daily)

Notes:

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 SENT VIA FAX OR EMAIL EVERY SUNDAY:
(305)894-0752 / DIABETES@SFPM.US