1. Sample Food, Physical Activity, and Blood Glucose Record Form
3-Day Food and Blood Glucose Record
Breakfast Example
Time: 7:30 CHO
Name _______________________ Date _________
choices: 4 1/2
o In the upper left-hand corner record the time of
Dose: 6 lispro
eating
o Underneath the time record your medication 1 ½ cup
dose(s) cornflakes
o In the center write down everything you eat ½ cup skim
and drink with the amount eaten milk
o In the upper right-hand corner record the ½ cup orange
number of carbohydrate (CHO) choices juice
o In the bottom left-hand corner record blood 1 slice toast
glucose (BG) before eating 1 tsp
o In the bottom right-hand corner record blood margarine
glucose 2 hours after starting eating BG Before: 152
o In the last column write down physical activity, BG After: 186
time, type, how long
Breakfast Snack Lunch Snack Evening Snack Activity
Meal
Time: CHO Time: CHO Time: CHO
CHO choices: choices: CHO choices: choices: CHO choices: choices:
Dose: Dose: Dose: Dose:
BG Before: BG Before: BG Before:
BG
BG After: BG After: BG After:
Before:
Time: CHO Time: CHO Time: CHO
CHO choices: choices: CHO choices: choices: CHO choices: choices:
Dose: Dose: Dose: Dose:
BG Before: BG Before: BG Before:
BG
BG After: BG After: BG After:
Before:

2. Time: CHO Time: CHO Time: CHO
CHO choices: choices: CHO choices: choices: CHO choices: choices:
Dose: Dose: Dose: Dose:
BG Before:
BG After: BG Before: BG Before:
BG
BG After: BG After:
Before:
Source: Adapted with permission from: Rickheim P, Flader J, Carstensen
KM: Type 2 Diabetes BASICS. Minneapolis MN: IDC Publishing; 2000.