Make a copy of this form for each week of your pregnancy. Use this form to keep track of your blood glucose numbers, your urine or blood ketone test results, and your insulin.
Week Starting: _____________ | Fasting Blood Glucose | Urine or Blood Ketones | Insulin | Breakfast Blood Glucose | Insulin | Other Blood Glucose | Insulin | Lunch Blood Glucose | Insulin | Other Blood Glucose | Insulin | Dinner Blood Glucose | Insulin | Other Blood Glucose | Insulin | Bedtime Blood Glucose | Insulin | Other Blood Glucose | Notes |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Monday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Tuesday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Wednesday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Thursday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Friday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Saturday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
|||||||||||
Sunday | Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |
Time: Amount: |