Hampton Roads Regional School Diabetes Medical Management Form (Page 2 of 2) in pdf

 In the event of a class party may eat the treat (include insulin coverage if

indicated in medical orders)

 student able to determine whether to eat the treat

 replace with parent supplied treat

 may NOT eat the treat

 other _____________________________

Child’s most common

 trembling

 tingling

 loss of coordination

signs of low blood

 dizziness

 moist skin/sweating

 slurred speech

glucose

 heart pounding

 hunger

 confusion

 weakness

 fatigue

 seizure

 pale skin

 headache

 unconsciousness

 change in mood or behavior

 other

________

How often does child

Mild

 once a day

 once a week

 once a month

experience low blood

Indicate date(s) of last mild episode(s)

glucose and how

severe?

Severe (i.e. unconscious, unable to swallow, seizure, or needed Glucagon)

Include date(s) of recent episode(s) ________________________________

Episode(s) of

Include date(s) of recent episode(s)

ketoacidosis

Field trips

Parent/guardian will accompany child during field trips?

 YES  NO

 Yes, if available

Serious illness, injuries

Date(s) and describe

or hospitalizations this

past year

List any other

medications currently

being taken

Allergies (include foods,

medications, etc):

Other concerns and

comments

I give permission to the school nurse and designated school personnel*, who have been trained and are under the

supervision of the school nurse to perform and carry out the diabetes care tasks as outlined in my child’s Diabetes

Medical Management Plan as ordered by the physician.

I give permission to the designated school personnel, who

have been trained to perform the following diabetes care tasks for my child. (Code of Virginia§ 22.1-274).

Insulin Administration

 YES

 NO

Glucagon Administration  YES

 NO

I understand that I am to provide all supplies to the school necessary for the treatment of my child’s diabetes. I also

consent to the release of information contained in the Diabetes Medical Management Plan to staff members and other

adults who have custodial care of my child and who may need to know this information to maintain my child’s health

and safety. I also give permission to contact the above named physician and members of the diabetes management

team regarding my child’s diabetes should the need arise.

Parent/Guardian Name _____________________________________________

Date ________________

Parent/Guardian Signature_____________________________________________________________________

School Nurse’s Name ______________________________________________

Date ________________

School Nurse’s Signature _____________________________________________________________________

*Note: If at any time you would like to have the names of the designated school personnel that have been trained,

please contact the school nurse. Names and training records are kept in the school clinic.

Hampton Roads Regional School Diabetes Medical Management Form Page 2

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