Microsoft Word - new diabetic form



Biloxi Public Schools Diabetes History and Action Plan*To be completed by healthcare provider*Student’s Name:_ DOBGrade Diabetes Type 1 Diabetes Type 2Hypoglycemia_ CURRENT MEDICATION PROFILEDrug Name:_ Amount:How Often: Drug Name:_ Amount:How Often: Drug Name:_ Amount:How Often: BLOOD GLUCOSE MONITORING:Target range for blood glucose: Usual times to check blood glucose: Can student perform own blood glucose checks?yesnoINSULIN:Insulin/Carbohydrate ratio:Correction Factor:_ Insulin correction dose at school: _Units if blood glucose is_to_mg/dl _Units if blood glucose is_to_mg/dl _Units if blood glucose is_to_mg/dl _Units if blood glucose is_to_mg/dlCan student give own injections?yesnoCan student determine correct amount of insulin?_yesno Can student draw correct dose of insulin?yesnoMEALS AND SNACKS EATEN AT SCHOOL:Is student independent in carbohydrate calculations and management?yesno Does student require scheduled snacks during school day?_yesnoIf yes, times for snacksamount of carbs EXERCISE AND SPORTS:Parent/guardian must provide all snacks for diabetic emergencies. Student should not exercise if blood glucose level is belowmg/dl or abovemg/dl . Other sports/exercise instructions_.STUDENTS WITH INSULIN PUMPS:Type of pump:Basal Rate: Type of insulin in pump: Insulin/Carbohydrate ratio:Correction Factor: Student pump abilities/skills:Count carbohydratesBolus correct amount for carbs consumed Calculate and administer corrective bolus Disconnect pumpReconnect pump at infusion site Prepare reservoir and tubing Insert infusion setTroubleshoot alarms and malfunctions yes no yes_no yes_no yesno yesno yesno yesno yesnoSUPPLIES TO BE KEPT AT SCHOOL: _Blood glucose meter, blood glucose_Insulin pump and supplies strips, batteries for meter _Lancet device, lancets Urine ketone strips _Insulin pen, pen needles Fast acting source of glucose _Insulin vials and syringes _Carbohydrate containing snacks Glucagon emergency kit (must complete medication form)HYPOGLYCEMIA:Usual symptoms of hypoglycemia_ Treatment of hypoglycemia HYPERGLYCEMIA:Usual symptoms of hyperglycemia: Treatment of hyperglycemia: Ketones should be checked when blood glucose level is above Treatment for ketones EMERGENCY CONTACTS: Relationship:Phone: Relationship:Phone: Relationship:Phone: IF UNABLE TO CONTACT PARENT/GUARDIAN WITH NUMBER LISTED ABOVE WITHIN A REASONABLE AMOUNT OF TIME 911 WILL BE CALLED! _Prescriber’s signatureDate _ Prescriber’s printed name _ Prescriber’s contact informationI agree with this planParent’s SignatureDate ................
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