29.12 Sick Day Record

Diabetes Planned Visit Notebook

Summa Health System developed this record for patients with diabetes to use to log their blood glucose and urine ketones on days when they are sick. Care providers give it to patients during diabetes planned visits, and it is part of the Diabetes Planned Visit Notebook.

Sick Day Record

Name: _________________________________________________________________________

Chart#: ________________________________________________________________________

Date: __________________________________________________________________________

Sick day treatment plan (your doctor or nurse will mark the testing that is right for you)

Check blood glucose & urine ketones at the times marked in the shaded box.

DateGlucose/KetonesBefore
Breakfast
2 Hr After
Breakfast
Before
Lunch
2 Hr After
Lunch
Before
Supper
2 Hr After
Supper
DateBlood
Glucose
      
 Urine
Ketones
      
DateBlood
Glucose
      
 Urine
Ketones
      
DateBlood
Glucose
      
 Urine
Ketones
      
DateBlood
Glucose
      
 Urine
Ketones
      
DateBlood
Glucose
      
 Urine
Ketones
      

When to call your doctor

Call your doctor at (330) 375-3584 or 1-800-460-2332 if:

  • Your blood sugar is over 240.
  • Your blood sugar is less than 80.
  • Ketone results are MODERATE or LARGE.
Page last reviewed January 2008
Internet Citation: 29.12 Sick Day Record: Diabetes Planned Visit Notebook. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk2912.html