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:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Tuesday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Wednesday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Thursday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Friday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Saturday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Sunday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     


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:
   Time:
Amount:
     
Tuesday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Wednesday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Thursday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Friday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Saturday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     
Sunday       Time:
Amount:
   Time:
Amount:
   Time:
Amount:
   Time:
Amount:
     

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