Blood Sugar Log
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1Office Phone: (602) 546-0935 (8:30 AM-4:30 PM, week-days)
Fax Number: (602) 546-0610
Phoenix Children’s Hospital Endocrinology and Diabetes Section
E-mail:
Date
Breakfast
Mid
Lunch
Mid
Evening Meal
Bedtime
2-3 AM
Comments
Morning
Afternoon
Blood
Blood
Insulin
Blood
Insulin
Blood
Insulin
Blood
Insulin
Blood
Blood
sugar
sugar
dose
sugar
dose
sugar
dose
sugar
dose
sugar
sugar
Date of Call:______________________ Time of Call:________________________ Hasan, MD Kaufmann, MD Touger, MD Dajani, MD Hudson, MD Belapurkar, MD
Person Calling:_______________________________________________________________________
Patient Name:_____________________________________
Phone: Home: (
)_______________ Work: (
)_______________ Fax: (
)____________
MR#:____________________________________________
E-mail:______________________________________________________________________________
New Insulin Dose: ______________ AM ______________ Lunch ______________ PM ______________ HS
Signature: _________________________________________
Comments: ___________________________________________________________________________
Signature: _________________________________________
_____________________________________________________________________________________
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