Overview

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