Name

DOCTOR'S PHONE USUAL DOSES OF INSULIN OR ORAL AGENT

Upon Arising
DOCTOR'S FAX Min Pre/post bkfst
Min Pre/post lunch
DOCTOR' E-MAIL Min Pre/post dinner
Min Pre/post snacks
At or Post Bedtime
DATE SUNDAY MONDAY
WEEK
BEGINS BLOOD MEDICATION BLOOD MEDICATION
/ / TIME TIME
SUGAR EXERCISE SUGAR EXERCISE
FOCO, etc FOCO, etc

1 AM
THRU
6 AM

6 AM
THRU
9 AM

9 AM
THRU
12 NOON

12 NOON
THRU
3 PM

3 PM
THRU
6PM

6 PM
THRU
9PM

9 PM
THRU
1 AM
 GlucograF IV DATA SHEET
1 Unit will BG EFFECTS OF
Lower Blood SWEETS (mg/dl)
Sugar mg/gl

TARGET BG 1 gm CHP
TARGET BG

TUESDAY WEDNESDAY THURSDAY

BLOOD MEDICATION BLOOD MEDICATION

TIME TIME TIME
SUGAR EXERCISE SUGAR EXERCISE
FOCO, etc FOCO, etc
G EFFECTS OF EXERCISE MISC
WEETS (mg/dl) ADJUSTMENTS

gm CHP

THURSDAY FRIDAY SATURDAY

BLOOD MEDICATION BLOOD MEDICATION BLOOD

TIME TIME
SUGAR EXERCISE SUGAR EXERCISE SUGAR
FOCO, etc FOCO, etc
SATURDAY

MEDICATION
EXERCISE
FOCO, etc