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High Blood Sugar Level Record
You can complete this form online and then print the form for easy reference. Only text that is visible on the
form is printed; scrolled text will not print. Any text you enter into these fields will be cleared when you close
the form; you cannot save it.
Use this form to record a high blood sugar level problem. Fill out a record each time this happens. Take the
completed form(s) to the doctor. If you or your child with diabetes is having high blood sugar problems, the
diabetes medicine dose may need to be adjusted or the medicine may need to be changed.
Date:
Time of day that the emergency occurred:
Symptoms:
Blood sugar levels during the emergency:
Was a dose of diabetes medicine missed?
Yes No
Did you (or your child) take it when the medicine was remembered?
Yes No
Was a dose of fast-acting insulin taken?
Yes No
If an insulin dose was taken, how much was taken?
units
Was emergency care needed?
Yes No
© 1995-2021 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo
are trademarks of Healthwise, Incorporated.
This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this
information.
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Completed 21 September 2021

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