Diabetic Blood Glucose Monitoring | Flitwick Surgery

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If you have been advised by the surgery to submit your Diabetic Blood Glucose Monitoring please use this form.

Diabetic Blood Glucose Monitoring

Diabetic Blood Glucose Monitoring

If you are human, leave this field blank.

Please complete the following over a two week period. We need a minimum of two readings per day. These need to be taken at alternate times each day and entered into the boxes below.

Section

Day 1

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 2

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 3

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 4

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 5

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 6

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 7

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 8

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 9

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 10

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 11

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 12

Date: *

Please use this date format: DD/MM/YYYY.

Before Breakfast Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

Day 13

Date: *

Please use this date format: DD/MM/YYYY.

Before Lunch Blood Glucose Reading *

Before Bed Blood Glucose Reading *

Day 14

Date: *

Please use this date format: DD/MM/YYYY.

Before Bed Blood Glucose Reading *

Before Dinner/Supper Blood Glucose Reading *

*

I confirm that the information provided is accurate to the best of my knowledge

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