Ambulatory Glucose Profile Report Form
Complete the Ambulatory Glucose Profile Report Form to document key glucose profile data, reporting period, and observations.
Report ID
*
Patient Initials
*
Date of Birth (YYYY-MM-DD)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Period Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Period End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Average Glucose (mg/dL)
*
Time in Range (70-180 mg/dL, %)
*
Time Above Range (>180 mg/dL, %)
*
Time Below Range (
*
Observed Glucose Patterns or Notes
Submit Report
Should be Empty: