First Name Last Name 01010101001/01/01Enter a number Lantus Enter a numberLantusHumalog1111 1

1

Name: First Name Last Name

MR: 010101010

DOB: 01/01/01

Date: June 6, 2018

Blood Glucose (mg/dl)	Breakfast Humalog	Lunch Humalog	Supper Humalog	Bedtime Humalog
<70	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 a meal.
70-90	0	0	0	0
91-130 (Base Dose)	1	1	1	0
131-150	2	2	2	0
151-200	3	3	3	0
201-250	4	4	4	0
251-300	5	5	5	1
301-350	6	6	6	2
351-400	7	7	7	3
401-450	8	8	8	4
>450	9	9	9	5
Take Enter a number units of Lantus at breakfast
Take Enter a number units of Lantus in the evening

Signature: