Form Sts 0119 - Diabetes Medical Management Plan (Dmmp)
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3St. Lucie Public Schools
Diabetes Medical Management Plan (DMMP) (School Year ____ - ____)
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Student Name ____________________________
DOB __________
Diabetes Type 1 ___ Type 2 ___ other___
Any known allergies (food or drug)______________________________________________________________________
CHECKING BLOOD GLUCOSE
Check blood glucose level: ( ) before lunch ( ) __hours after lunch ( ) ___ hours after a correction dose ( ) mid morning
( ) before PE ( ) after PE ( ) before dismissal ( ) other _____________ ( ) as needed for signs/symptoms of high or low
glucose levels ( ) as needed for signs/symptoms of illness
Location of glucose monitoring: ( ) classroom ( ) clinic ( ) other ______________
Students self care skills ( ) Independently checks own blood glucose ( ) May check blood glucose with supervision
( ) Requires trained personnel to check blood glucose
Continuous blood glucose monitor (CGM) ( ) yes ( ) no Brand/ model_____________________ Alarms set for ( ) high ( ) low
Note: Always confirm CGM results with blood glucose meter before taking action
INSULIN THERAPY
Student Self Care Insulin Skills
( ) Independently calculates and gives own injections ( ) Requires trained personnel to calculate / administer insulin
( ) May calculate/ give own injection with supervision
When to give insulin:
( ) Lunch: ( ) Breakfast ( ) carbohydrate coverage only ( ) carbohydrate coverage plus *correction dose when blood glucose is
greater than ___ mg/dl and ___ hours since last insulin dose ( ) fixed dose ( ) other ___________
( ) Snacks: ( ) no coverage for snack ( ) carbohydrate coverage only ( ) carbohydrate coverage plus *correction dose when
blood glucose is greater than ___ mg/dl and __ hours since last insulin dose ( ) other _____________
( ) Correction dose only: For blood glucose greater than ___mg/dl AND at least __ hours since last insulin dose.
*Note: Correction dose may require deduction of insulin from carbohydrate coverage if blood glucose is less than target ( ) yes ( ) No
Insulin type: ( ) Regular ( ) Humalog ( ) Novolog ( ) Apidra
Delivery system: ( ) pen ( ) syringe ( ) pump
( ) Correction dose formula: Blood glucose minus
( ) Carbohydrate to insulin ratio: 1 unit per ______
_________ divided by ________ = Insulin dose
grams of carbohydrate
( ) Correction dose sliding scale:
( ) Fixed standard daily dose at school:
Blood glucose: _____________ Insulin dose __________
Type: _____________ Dose: ____ Time: _____
Blood glucose: _____________ Insulin dose __________
Type: _____________ Dose: ____ Time :_____
Blood glucose: _____________ Insulin dose __________
Blood glucose: _____________ Insulin dose __________
Blood glucose: _____________ Insulin dose __________
Blood glucose: _____________ Insulin dose __________
OTHER ROUTINE DIABETES MEDICATIONS AT SCHOOL
Medication Name ___________________ Dose __________________ Route ________________ Time ___________________
MEAL PLAN
(Meal times are approximate due to school schedule issues)
Meal/ Snack
Time
Carbohydrate Content (grams)
(if known)
Breakfast
_______________
______ to ______
Mid morning snack
_______________
______ to ______
Lunch
_______________
______ to ______
Mid afternoon snack
_______________
______ to ______
Activity snacks: ___grams of carbohydrates ( ) before ( ) every 30 minutes during ( ) after strenuous activity
Other: ________________________If blood glucose is less than ___mg/dl before exercise (PE) give ____grams of carbohydrate
MD Initials ________
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