Date: ___________________________________________ Date: ___________________________________________ Date: ___________________________________________

Name: __________________________________________
Time Score Meal/Snack Dose Time Score Meal/Snack Dose Time Score Meal/Snack Dose
F: F: F:
Week: __________________________________________
C: C: C:
Total Carbs: T: Total Carbs: T: Total Carbs: T:
Target Score: ___________________________________

Mid Morn Breakfast

Mid Morn Breakfast
Mid Morn Breakfast

F: Humalog Ratio: _________________________________

F: F:
C: C: C:
T: T: T: Insulin
Correction Factor: ______________________________

Lunch
Lunch
Lunch

Total Carbs: Total Carbs: Total Carbs:

Carb
Correction Factor: ______________________________

Mid Aft
Mid Aft
Mid Aft

F: F: F: Lantus: _______________Time: ____________________

C: C: C:
T: T: T:

Supper
Supper
Supper
Total Carbs: Total Carbs: Total Carbs:

Evening
Evening
Evening
NOTES

Night
Night
Night

Night
Night
Night

Night

Evening
Evening
Evening

Evening
Total Carbs: Total Carbs: Total Carbs: Total Carbs:

Supper
Supper
Supper

Supper
T: T: T: T:
C: C: C: C:
F: F: F: F:

Mid Aft
Mid Aft
Mid Aft

Mid Aft
Total Carbs: Total Carbs: Total Carbs: Total Carbs:

Lunch
Lunch
Lunch

Lunch
T: T: T: T:
C: C: C: C:
F: F: F: F:
T: Total Carbs: T: Total Carbs: T: Total Carbs: T: Total Carbs:
C: C: C: C:

Mid Morn Breakfast

Mid Morn Breakfast
Mid Morn Breakfast

Mid Morn Breakfast

F: F: F: F:
Dose Meal/Snack Score Time Dose Meal/Snack Score Time Dose Meal/Snack Score Time Dose Meal/Snack Score Time
Date: ___________________________________________ Date: ___________________________________________ Date: ___________________________________________ Date: ___________________________________________