Blood Sugar Readings

If you have been advised by the surgery to submit your blood sugar readings, please use this form.

Blood Sugar Monitoring

Section

Smoking Status:

Your Blood Sugar Levels

Please provide two whole weeks of blood sugar readings, taken 4 times a day.

Day 1

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 2

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 3

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 4

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 5

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 6

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 7

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 8

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 9

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 10

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 11

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 12

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 13

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol

Day 14

Please use date format: DD/MM/YYYY
In mmol
In mmol
In mmol
In mmol
*