High and Low Blood Sugar Level Record for a Child

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Low blood sugar level

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

Date: ____________ Time: __________

Activity before low blood sugar:

Time the medicine was last given, and the amount given:

Symptoms:


How long symptoms lasted:

Blood sugar levels during the problem:

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

Was glucagon given (only for children who take insulin)? ___ Yes ___ No

Was emergency care needed? ___ Yes ___ No

High blood sugar level

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

Date: ____________ Time: __________

Did your child seem sick? If so, what were the symptoms?


What was he or she doing before the episode?


High blood sugar symptoms:


Blood sugar levels during the problem:

Was a dose of diabetes medicine missed? Did you give it after you remembered?

Was a dose of fast-acting insulin given? If so, what was the dose? ____ units

Was emergency care needed? __ Yes __ No

Credits

Current as of: April 16, 2019

Author: Healthwise Staff
Medical Review: John Pope, MD, MPH - Pediatrics
Adam Husney, MD - Family Medicine
Kathleen Romito, MD - Family Medicine
Stephen H. LaFranchi, MD - Pediatric Endocrinology