"Weekly Blood Glucose & Meal Log Template"

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Blood Glucose & Meal Log
WEEK OF: ______________
NAME: __________________________
Breakfast
Lunch
Dinner
Bedtime
Date
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
8am /148
10am /160
12pm /97
2:30pm /102
6pm /116
9pm /155
Example
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
veg omlet - 6
Ham sand-34
1 orange- 20
Roast Beef - 0
¼ c Almonds
Milk-11 carb
ice tea-0
1 potato-37
2 unit aspart
3 unit aspart
4 units aspart
10 unit Lantus
Insulin:
Walk 15 min
Walk 15 min
Walk 15 min
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
MON
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
TUE
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
WED
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
VA/DoD Clinical Practice Guideline for Diabetes Mellitus
https://www.qmo.amedd.army.mil  http://www.healthquality.va.gov
Blood Glucose & Meal Log
WEEK OF: ______________
NAME: __________________________
Breakfast
Lunch
Dinner
Bedtime
Date
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
Time/BG
8am /148
10am /160
12pm /97
2:30pm /102
6pm /116
9pm /155
Example
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
veg omlet - 6
Ham sand-34
1 orange- 20
Roast Beef - 0
¼ c Almonds
Milk-11 carb
ice tea-0
1 potato-37
2 unit aspart
3 unit aspart
4 units aspart
10 unit Lantus
Insulin:
Walk 15 min
Walk 15 min
Walk 15 min
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
MON
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
TUE
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
WED
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
VA/DoD Clinical Practice Guideline for Diabetes Mellitus
https://www.qmo.amedd.army.mil  http://www.healthquality.va.gov
Blood Glucose & Meal Log
WEEK OF: ______________
NAME: __________________________
Breakfast
Lunch
Dinner
Bedtime
Date
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
THU
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
FRI
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
SAT
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
Time/BG:
SUN
Food/Carbs:
Food/Carbs:
Food/Carbs:
Food/Carbs
Insulin:
Activity:
VA/DoD Clinical Practice Guideline for Diabetes Mellitus
https://www.qmo.amedd.army.mil  http://www.healthquality.va.gov
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