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.
Time of day that the emergency occurred: ___________________
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
Current as of:
March 1, 2023
Author: Healthwise Staff Medical Review: E. Gregory Thompson MD - Internal Medicine Adam Husney MD - Family Medicine Kathleen Romito MD - Family Medicine Rhonda O'Brien MS, RD, CDE - Certified Diabetes Educator
Medical Review:E. Gregory Thompson MD - Internal Medicine & Adam Husney MD - Family Medicine & Kathleen Romito MD - Family Medicine & Rhonda O'Brien MS, RD, CDE - Certified Diabetes Educator
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