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Low Blood Sugar Level Record

Table of Contents


Topic Overview

Use this form to record a low blood sugar level problem. Fill out a record each time this happens. Take the completed form(s) to the doctor. If you (or your child with diabetes) is having low blood sugar problems, the diabetes medicine dose may need to be adjusted or the medicine may need to be changed.

Date: ____________ Time: __________

Time that the last dose of medicine was given and the amount:

Symptoms, if any:




How long symptoms lasted:

Blood sugar levels during the problem:

Activity before low blood sugar:

Kind and amount of glucose or sucrose tablets or solution or other quick-sugar food that was taken:




Was glucagon given? __ Yes __ No

Was emergency care needed? __ Yes __ No


Credits for Low Blood Sugar Level Record

Current as of: August 31, 2020

Author: Healthwise Staff
Medical Review: E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
Kathleen Romito MD - Family Medicine
Rhonda O'Brien MS, RD, CDE - Certified Diabetes Educator


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