Medical Authorization Form For Diabetic Management Form Page 2
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2Attachment 1 Reg. No. 400-80
MISCELLANEOUS INSTRUCTIONS
Meal Plan
AM snack, time: _________
PM snack, time: _________
Avoid snack if blood glucose greater than ______mg/dl.
Lunch: ___________________________________ Extra food allowed
Parent’s discretion
Student’s discretion
Exercise (check and/or complete all that apply)
Fast-acting carbohydrate source must be available before, during and after all exercise.
With student
With Teacher
If most recent blood glucose is less than ____________, exercise can occur when blood glucose is corrected and above ___________.
Eat __________ grams of carbohydrate
Before
Every 30 minutes during
After vigorous exercise
Avoid exercise when blood glucose is greater than _________________ or ketones are _______________.
Bus Transportation
Blood glucose monitoring not required prior to boarding bus
Check blood glucose 15 minutes prior to boarding bus
Allow student to eat on bus if having symptoms of low blood glucose
Provide care as follows:______________________________________________________________________________________
Health Care Provider Assessment / Student’s Independent Self-Care
Student can self-perform the following procedures (school nurse and parent must verify competency):
Blood glucose monitoring
Measuring insulin
Injecting insulin
Determining insulin dose
Independently operating insulin pump
Other:_______________________________________________________________
Disaster Plan (if needed for lockdown, 24 hr shelter in place)
Additional insulin orders as follows:___________________________________
Administer long acting insulin as follows: _______________________________________________________________________
Other: ____________________________________________________________________________________________________
Other Instructions:
HEALTH CARE PROVIDER AUTHORIZATION
Health Care Provider’s Name/Title: (Type or Print)
Telephone:
Fax:
Use for Health Care Provider’s Address Stamp
Address:
Health Care Provider’s Signature:
Date:
PARENT/GUARDIAN AUTHORIZATION
I request designated staff to administer the medication/treatment as prescribed by the health care provider above. I certify
that I have legal authority to consent to the administration of medication/treatment at school.
Parent/Guardian Signature:
Date:
Parent/Guardian Phone:
Work Phone:
Order reviewed and signed by school registered nurse:
Date:
3/05
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