Sample food physical_activity_and_blood_glucose_record

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  • 1. Sample Food, Physical Activity, and Blood Glucose Record Form3-Day Food and Blood Glucose RecordBreakfast Example Time: 7:30 CHOName _______________________ Date _________ choices: 4 1/2 o In the upper left-hand corner record the time of Dose: 6 lispro eating o Underneath the time record your medication 1 ½ cup dose(s) cornflakes o In the center write down everything you eat ½ cup skim and drink with the amount eaten milk o In the upper right-hand corner record the ½ cup orange number of carbohydrate (CHO) choices juice o In the bottom left-hand corner record blood 1 slice toast glucose (BG) before eating 1 tsp o In the bottom right-hand corner record blood margarine glucose 2 hours after starting eating BG Before: 152 o In the last column write down physical activity, BG After: 186 time, type, how longBreakfast Snack Lunch Snack Evening Snack Activity MealTime: CHO Time: CHO Time: CHOCHO choices: choices: CHO choices: choices: CHO choices: choices:Dose: Dose: Dose: Dose:BG Before: BG Before: BG Before: BGBG After: BG After: BG After: Before:Time: CHO Time: CHO Time: CHOCHO choices: choices: CHO choices: choices: CHO choices: choices:Dose: Dose: Dose: Dose:BG Before: BG Before: BG Before: BGBG After: BG After: BG After: Before:
  • 2. Time: CHO Time: CHO Time: CHOCHO choices: choices: CHO choices: choices: CHO choices: choices:Dose: Dose: Dose: Dose:BG Before:BG After: BG Before: BG Before: BG BG After: BG After: Before:Source: Adapted with permission from: Rickheim P, Flader J, CarstensenKM: Type 2 Diabetes BASICS. Minneapolis MN: IDC Publishing; 2000.