How about this one?

USE: ( ICR 1: 5 )

1 units of insulin : for every 5 carbs consumed with the following snack (click to see how much carbs in each)

1 banana (__ grams of carbs) + 1 tablespoon of peanut butter (__ grams of carbs ) =___ total grams of carbs

Total grams of carbs ___ divided by 5 [our ICR number] is ____ (the amount to take)