Diabetes Flow Sheet
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1Plaza 3
1315 S. Cliff Ave., Suite 3000
Sioux Falls, SD 57105
605-322-7600 • Fax: 605-322-7601
Insulin Ratio/CHO:
Correction Factor:
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Pre-
Post-
Pre-
Post-
Pre-
Post-
Date
Bedtime 3:00 AM
Early AM
Comments
Breakfast
Breakfast
Noon
Noon
Dinner
Dinner
Blood
Glucose
Insulin
CHO
Time:______________ Date:______________ Patient Signature:_______________________________________
Diabetes Flow Sheet -
Form 7376-18 PS (English) (Rev. 4/09)
Avera Medical Group Endocrinology & Diabetes
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