Cys Services Snap Diabetes Medical Action Plan Template
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2CYS SERVICES SNAP DIABETES MEDICAL ACTION PLAN
(to be completed by Health Care Provider)
NOTE TO HEALTH CARE PROVIDER: CYS staff/providers CANNOT administer insulin/glucagon injection, adjust insulin pumps and/or count carbohydrates.
Staff/providers CAN perform blood glucose checks, keep food diary/log and administer oral agents, i.e. glucose jell, orange juice
Child/Youth’s Name
Date of Birth
Date
Sponsor Name
Health Care Provider
Health Care Provider Phone
Hypoglycemia (Low Blood Sugar) Symptoms
□ Shakiness
□ Weak
□ Pale or flushed face
□ “Feels hungry”
□ Sweaty
□ “Feels low”
□ Confused
□ Headache
□ Looks dazed
□ Other:
______________________________
Treatment of Hypoglycemia (CYS Staff/providers are NOT authorized to give injections, but will monitor those children who
self administer)
If blood sugar is _______ to _______, then do nothing; this is in the normal range.
If blood sugar is less than_______, and child can speak or swallow, then give snack of _________________ , then check
sugar in _____ minutes.
If blood sugar is less than _______ then call parent/guardian.
EMERGENCY
If blood sugar is less than _______ , then CALL 911 and call parent/guardian.
Additional instructions (to include the use of oral rescue medications):
RESPONSE
Hyperglycemia (High Blood Sugar) Symptoms
□ Unable to concentrate
□ Stomach ache
□ Frequent thirst
□ Heavy breathing
□ Frequent urination
□ Combative behavior/personality changes
□ Nausea
□ Other: ___________________________
Treatment of Hyperglycemia
If blood sugar is _______ to _______, then do nothing; this is in the normal range.
If blood sugar is above _______, then notify parent/guardian.
EMERGENCY
If blood sugar is above _______, then CALL 911 and notify parent/guardian.
Additional Instructions:
RESPONSE
Follow Up
This Diabetes Medical Action Plan must be updated/revised whenever medications or child/youth’s health status
changes. If there are no changes, the Diabetes Medical Action Plan must be updated at least every 12 months.
Form Updated 2 Feb 09
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Parent category: Medical