Diabetic Blood Glucose Monitoring | Upper Halliford Medical Centre

Online Requests

Form only to be completed if requested by the practice.

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

Diabetic Blood Glucose Monitoring

If you are human, leave this field blank.

Please complete the following over a one 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.

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 *

*

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

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