Overview
Low blood sugar level
Use this form to record a low blood sugar level problem. Fill out a record each time this happens. Take the completed form(s) with you when you visit your child's doctor. If your child is having low blood sugar problems, his or her medicine for diabetes may need to be adjusted or changed.
Date: ____________ Time: __________
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Activity before low blood sugar:
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Time the medicine was last given, and the amount given:
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Symptoms:
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How long symptoms lasted:
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Blood sugar levels during the problem:
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Kind and amount of glucose or sucrose tablets or solution or other quick-sugar food that was taken:
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Was glucagon given (only for children who take insulin)? ___ Yes ___ No
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Was emergency care needed? ___ Yes ___ No
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High blood sugar level
Use this form to record a high blood sugar level problem. Fill out a record each time this happens. Take the completed form(s) with you when you visit your child's doctor. If your child is having high blood sugar problems, his or her medicine for diabetes may need to be adjusted or changed.
Date: ____________ Time: __________
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Did your child seem sick? If so, what were the symptoms?
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What was he or she doing before the episode?
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High blood sugar symptoms:
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Blood sugar levels during the problem:
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Was a dose of diabetes medicine missed? Did you give it after you remembered?
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Was a dose of fast-acting insulin given? If so, what was the dose? ____ units
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Was emergency care needed? __ Yes __ No
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Credits
Current as of:
March 1, 2023
Author: Healthwise Staff
Medical Review:
John Pope MD - Pediatrics
Adam Husney MD - Family Medicine
Kathleen Romito MD - Family Medicine
Stephen LaFranchi MD - Pediatrics, Pediatric Endocrinology
