Sample Food, Physical Activity, and Blood Glucose Record Form 3-Day Food and Blood Glucose Record Breakfast Example Name _______________________Date _________

o In the upper left-hand corner record the time of eating

o Underneath the time record your medication dose(s)

o In the center write down everything you eat and drink with the amount eaten

o In the upper right-hand corner record the number of carbohydrate (CHO) choices

o In the bottom left-hand corner record blood glucose (BG) before eating

o In the bottom right-hand corner record blood glucose 2 hours after starting eating

o In the last column write down physical activity, time, type, how long

Time: 7:30 CHO

choices: 4 1/2

Dose: 6 lispro

1 ½ cup cornflakes ½ cup skim milk ½ cup orange juice 1 slice toast 1 tsp margarine BG Before: 152

BG After: 186

Breakfast Snack Lunch Snack Evening Snack Activity Meal Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Dose:

BG

Before:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Dose:

BG

Before:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Time:

CHO choices:

Dose:

BG Before:

BG After:

CHO

choices:

Dose:

BG

Before:

Source: Adapted with permission from: Rickheim P, Flader J, Carstensen KM: Type 2 Diabetes BASICS. Minneapolis MN: IDC Publishing; 2000.