Form Mcs-240 - Individual Health Plan - Diabetic Management
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1MCS-240 Rev. 5/16
Individual Health Plan - Diabetic Management
Date of IHP_______________________
Student Name ______________________________ ID# ___________ HR/Team ______________Bus #/Car____________________
Diabetes Type 1 ___ Diabetes Type II ___ Age at diagnosis ______ Insulin Type? Humalog ___ Novolog ___ Lantus Y __ N __
Time of Day _____Target BG _____Carbohydrate ratio ___ Correction factor ___ Treats BG as low at: ___ Tests ketones if BG is: ____
Time of Day _____Target BG _____Carbohydrate ratio ___ Correction factor ___ Treats BG as low at: ___ Tests ketones if BG is: ____
Insulin Delivery: Pump____ Pen____ Syringe____ Date Rec. __________ Expiration (if applicable) _________
Altered Blood Sugar Response: Glucagon provided? Y___ N___ Expires________ Location __________________
Ketostix provided? Y___ N___ Expire _________ Location __________________
Blood sugar monitoring:
Independent ___ Assistance/Observation required___ Dependent___
Carbohydrate calculation: Independent ___ Assistance/Observation required___ Dependent___ Provided by parent___
Insulin dosage calculation: Independent ___ Assistance/Observation required___ Dependent___
Insulin administration:
Independent ___ Assistance/Observation required___ Dependent___
Insulin pump site change will be completed by: Student___ Parent___ Site change supplies stored in clinic? Y___ N___
Student manages diabetes: Only in clinic___ In both clinic and classroom___ Only in classroom___
Student checks BG: At meals___ Prior to PE___ Following PE___ End of school day___ When symptomatic___ Other___________
School hour BG/Insulin intake reported to parent by: Student___ Pump___ Nurse___ (Email___ Phone___ Note___)
Student’s primary symptoms of Hypoglycemia (LOW BLOOD SUGAR) usually include: (circle all that apply)
Shaky
Sweaty
Dizzy
Anxious
Hungry
Other:
Blurry Vision
Weakness
Headache
Irritability
Tachycardia
Other:
Student’s primary symptoms of Hyperglycemia (HIGH BLOOD SUGAR) usually include: (circle all that apply)
Extreme Thirst
Frequent urination Hungry
Drowsy
Blurry Vision
Skin Dryness
Other:
Signature of person completing form:_____________________________Date_____________
CLINIC USE ONLY: To be filled out by clinic RN
Physician orders received Y_____N____Date______Parent/Guardian notified of 504 Eligibility____Date________
Testing supplies (glucometer, strips, lancets, alcohol swabs, batteries, pump replacement tubing /site changes)
Supplies received: Date___________Exp dates:____________Location(s)__________________________________
Transportation notified/IHP sent
Date:
Initials:
Food service Notified
Date:
Initials:
Teachers/Appropriate staff/IHP sent
Date:
Initials:
Notes:_____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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