Continuous Glucose Monitoring Patch Log Form
Record your CGM patch usage, device details, site, status, and observations. Please complete all relevant fields for an accurate patch log.
Wearer or Patient Identifier (e.g., initials, nickname, or user code)
*
Patch Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patch Start Time
*
Hour Minutes
AM
PM
AM/PM Option
CGM Device or Patch Brand/Model
*
Please Select
Dexcom G6
Dexcom G7
Freestyle Libre
Medtronic Guardian
Other
Sensor or Patch Site Location
*
Please Select
Upper Arm (Left)
Upper Arm (Right)
Abdomen (Left)
Abdomen (Right)
Lower Back
Other
Patch Status Today
*
Active
Changed
Removed
Malfunctioning
Other
Current Reading or Observed Glucose Trend Note
Skin or Adhesive Issue Observed
None
Mild irritation
Redness
Peeling
Discomfort
Other
Patch Change Date/Time or Replacement Timing Note
Additional Notes or Comments
Submit Log
Should be Empty: