DAILY BLOOD GLUCOSE
DAILY FOOD RECORD
Write down everything you ate, drank, chewed, or swallowed for the three days of blood testing. Tell us the amounts and how you cooked the foods.

Blood Test Date

      Time          Date______ Time          Date______ Time          Date______
Fasting       Breakfast    
1 Hour After Breakfast      
       
1 Hour After Lunch      
        Snack    
1 Hour After Dinner      
9-10 PM/Bedtime      
Optional 2 AM       Lunch    
Fasting Urine Ketone      
Insulin AM Reg      
NPH      
Insulin PM Reg       Snack    
NPH      
Check Any That Apply      
Illness:       Dinner    
Overeating/Skipped Meals      
Exercise (walking, etc.)      
Kick Counts       Times      
Family or Personal problems:
1)Mild
2)Moderate
3)Severe
    (write number)
      Snack    
Target range for capillary blood glucose: Fasting 65-100; 1 hour 110-135; 2 hours  <120