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Daily Metabolic Disorder Tracking Sheet

Patient Self-Monitoring Documentation Tool

Endocrinology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date: //___ Diagnosis: ___________________ Provider: ___________________

Vital Signs

  • Blood Pressure: / mmHg (Time: _____)
  • Heart Rate: _____ bpm
  • Weight: _____ lbs/kg
  • Temperature: _____ °F/°C

Blood Glucose Monitoring

Time Reading Before/After Meal Medications Taken
AM
Noon
PM
Night

Dietary Intake

Carbohydrates

Breakfast: _____ g Lunch: _____ g Dinner: _____ g Snacks: _____ g

Physical Activity

  • Type of activity: ___________________
  • Duration: _____ minutes
  • Intensity (circle): Light / Moderate / Vigorous

Symptoms (Check if present)

□ Fatigue □ Dizziness □ Excessive thirst □ Frequent urination □ Vision changes □ Other: ___________________

Notes

Medication changes: ________________________________________________ Unusual events: __________________________________________________

Emergency Contacts

Provider: _____________________ Phone: _____________________ Emergency Contact: _____________ Phone: _____________________

Bring this log to all medical appointments

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