U.S. Department of Health and Human Services

My Daily Blood Glucose Record

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.

My Daily Blood Glucose Record
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 Notes
Monday Time:
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Tuesday Time:
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Wednesday Time:
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Thursday Time:
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Friday Time:
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Saturday Time:
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Sunday Time:
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My Daily Blood Glucose Record (Continued)
Week Starting: _____________ Fasting Blood Glucose Urine or Blood Ketones Insulin Dinner Blood Glucose Insulin Other Blood Glucose Insulin Bedtime Blood Glucose Insulin Other Blood Glucose Notes
Monday Time:
Amount:
Time:
Amount:
Time:
Amount:
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Amount:
Tuesday Time:
Amount:
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Wednesday Time:
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Thursday Time:
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Friday Time:
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Saturday Time:
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Sunday Time:
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