North East Independent School District
10333 Broadway – SAN ANTONIO, TEXAS 78217
Diabetes Management and Treatment Plan
Department of
Health Services
Physician/Parent Authorization for Diabetes Care
Student: ____________________________________ Date of Birth: _______________ Grade: ____________
School: _______________________________ Nurse: ___________________Fax Number: _______________
TO BE COMPLETED BY PHYSICIAN:
1. PROCEDURES: Parent will provide all supplies for procedures.
A. Blood Glucose Monitoring
Usual times to check blood glucose ______________________________________________________
Target range for blood glucose is _____ 70-150 _____ 70-180 _____ Other ______________________
Times to do extra blood glucose checks (check all that apply)
Before exercise
After exercise
When student exhibits symptoms of hyperglycemia
When student exhibits symptoms of hypoglycemia
Other (explain) ___________________________________________________________________
Can student perform own blood glucose checks?
Yes
No
Exceptions ______________________________________________________________________
Type of blood glucose meter student uses ______________________________________________
B. Test Urine ketones when student is hyperglycemic and/or when student is ill.
Yes
No
2. MEDICATION:
A. Insulin
Usual Lunchtime Dose: To be given subcutaneously within 30 minutes prior to lunchtime.
1) Base dose of Humalog®/Novolog®/Regular insulin (circle type of rapid/short-acting insulin used):
__________ units plus Insulin Correction Scale; OR
2) Flexible dosing using __________ units of insulin per __________ grams of carbohydrate plus
Insulin Correction Scale.
3) Other insulin at lunch (circle type of intermediate insulin used):
Intermediate/NPH®/Lente® __________ units OR
Basal/Lantus®/Ultralente® __________ units
B. Oral Diabetes medication
Medication: ____________________________________ Dose: __________ Time: __________
C. Insulin Correction
1) Parent authorization should be obtained before administering a correction dose for high blood
glucose levels.
Yes
No
2) Insulin correction scale
____________________ units if blood glucose is ________ to ________ mg/dl
____________________ units if blood glucose is ________ to ________ mg/dl
____________________ units if blood glucose is ________ to ________ mg/dl
1
1
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