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Dr.

__________ Info for: Example & Instructions Patient: ____________

Time CGM MBG Carbs Protein Fat Bolus Basal Metformin Lisinopril B Fast Lunch Dinner Snack Notes
2p 243 1.00 1000mg 5mg
3p 322 1.00
3.3p 342 3 7 15 1.20 1000mg
296 1.20
293 86 13 0.80 1000mg
139 0.80
155 1.00
171 1.00
194 1.15
204 85 10 1.15
199 20 3 4 1.3 1.15
155 1.5 1.15 Fish + Nuts Fish+Salad
9:00p 197 1.00 1000mg
9.00p 1.00
1.00

1.00
15 38 22 1.00
1.00

1.20
1.20
18 1 0.5 5 1.20
41 35 1.015 1.20
214 13 2.5 1.20
Average 223 86 38% 24% 39% 1.36 1.07
Total 133 84 61 6.80 24.60
calories → 1,417 insulin → 31.40

350 0.0
1.0 1.0 1.2 1.2 0.8 0.8 1.0 1.0 1.2 1.2 1.2 1.2 1.0 1.0 1.0 1.0 1.0 1.0 1.2 1.2 1.2 1.2 1.2
342
1.0
0.5
322 1.3 1.0
1.5 2.0
300 2.5
296 293 3.0
4.0
250
243 5.0

214
6.0
200 204
194
199 197 7.0

171 8.0
155
150 155
9.0
139
10.0
100 86
11.0
85
12.0
50 13.0

41 14.0
13 20 15 18 13
10
0 3 15.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Fat (g) Protien (g) Carbs (g) CGM Meter Bolus Basal

564652341.xls Example & Instructions


Dr. _______________ Info for: blank sheet (patient name)
Time CGM MBG Carbs Protein Fat Bolus Basal Notes
12:00 AM 100
1:00 AM 200
2:00 AM 120
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
Average 140 ### ### #DIV/0! ### ### #DIV/0!
Total 0 0 0 0.00 0.00
calories → 0 insulin → 0.00

350 0.0
1.0

300 2.0

3.0
4.0
250
5.0
6.0
200
200
7.0
8.0
150
9.0

120
10.0
100
100 11.0
12.0
50 13.0
14.0

0 15.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Fat (g) Protien (g) Carbs (g) CGM Meter Bolus Basal

564652341.xls blank sheet

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