Patient Name

MRNDOBEnter a number2Enter a number2

Name: Patient Name

MR: MRN

DOB: DOB

Date: March 27, 2014

Blood Glucose (mg/dl)	Breakfast Insulin 70/30	Supper Insulin 70/30
70 or below	Treat the low blood sugar. Recheck blood glucose in 15 mins. If sugar is more than 70, then take the number of units of insulin in the 70-90 row, if before breakfast or supper.
71-90	0	0
91-130 (Base Dose)	Enter a number	Enter a number
131-150	2	2
151-200	4	4
201-250	6	6
251-300	8	8
301-350	10	10
351-400	12	12
401-450	14	14
451 and above	16	16

Signature: ___________________________________________