Alert

Low Blood Sugar Level Record

Topic Overview

Use this form to record a low blood sugar level problem. Fill out a record each time this happens. Take the completed form(s) to the doctor. If you (or your child with diabetes) is having low blood sugar problems, the diabetes medicine dose may need to be adjusted or the medicine may need to be changed.

Date: ____________ Time: __________

Time that the last dose of medicine was given and the amount:

Symptoms, if any:


How long symptoms lasted:

Blood sugar levels during the problem:

Activity before low blood sugar:

Kind and amount of glucose or sucrose tablets or solution or other quick-sugar food that was taken:


Was glucagon given? __ Yes __ No

Was emergency care needed? __ Yes __ No

Date: ____________ Time: __________

Time that the last dose of medicine was given and the amount:

Symptoms, if any:


How long symptoms lasted:

Blood sugar levels during the problem:

Activity before low blood sugar:

Kind and amount of glucose or sucrose tablets or solution or other quick-sugar food that was taken:


Was glucagon given? __ Yes __ No

Was emergency care needed? __ Yes __ No

Credits

Current as ofJuly 25, 2018

Author: Healthwise Staff
Medical Review: E. Gregory Thompson, MD - Internal Medicine
Adam Husney, MD - Family Medicine
Kathleen Romito, MD - Family Medicine
Rhonda O'Brien, MS, RD, CDE - Certified Diabetes Educator

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