Diabetes Action Plan Form
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1
2
3
4School
D istrict
1 45-‐
W averly
P ublic
S chools
Diabetes
A ction
P lan
DATE:
_ _____________
The
s tudent’s
p ersonal
h ealth
c are
t eam
a nd
p arents/guardian
s hould
c omplete
t his
a ction
p lan
f orm.
I t
s hould
b e
r eviewed
w ith
relevant
s chool
s taff
a nd
c opies
s hould
b e
k ept
i n
a
p lace
t hat
i s
e asily
a ccessed
b y
t he
s chool
n urse,
t rained
d iabetes
p ersonnel,
a nd
other
a uthorized
p ersonnel.
Student’s
N ame:
_ __________________________________________
Grade:
_ __________
School:
_ _____________________
Date
o f
B irth:
_ _________
Date
o f
D iabetes
D iagnosis:
_ ________________
Physical
C ondition:
D iabetes
t ype
1
D iabetes
t ype
2
CONTACT
I NFORMATION:
Parent(s)/Guardian:
_ __________________________________________________________________________________________
Phone
n umbers
f or
e mergencies_________________________________________________________________________________
Emergency
C ontact:
_ __________________________________________________________________________________________
Telephone
n umber(s)
_ _________________________________________________________________________________________
Student’s
D octor/Health
C are
P rovider:
_ __________________________________________________________________________
Doctor’s
c linic
n ame
_ ________________________________________________________
Telephone
_ __________________
Address:
_ ___________________________________________________________________________________________________
Notify
p arents/guardian
i n
t he
f ollowing
s ituations:
_ ________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
HYPOGLYCEMIA
( Low
B lood
S ugar)
Usual
S ymptoms
o f
h ypoglycemia:
_ ______________________________________________________________________________
____________________________________________________________________________________________________________
Treatment
o f
h ypoglycemia:
_ ___________________________________________________________________________________
____________________________________________________________________________________________________________
Glucagon
s hould
b e
g iven
i f
t he
s tudent
i s
u nconscious,
h aving
a
s eizure
( convulsion),
o r
u nable
t o
s wallow.
I f
glucagon
i s
r equired,
a dminister
i t
p romptly
t hen
c all
9 11
( or
o ther
e mergency
a ssistance),
t he
s chool
n urse,
a nd
t he
parents/guardian.
Route
_ ____________
D osage
_ ____________________
S ite
f or
g lucagon
i njection:
_ ____
a rm,
_ ___
t high,
_ _____________other.
HYPERGLYCEMIA
( High
B lood
S ugar)
Usual
S ymptoms
o f
h yperglycemia:
_ _____________________________________________________________________________
____________________________________________________________________________________________________________
Treatment
o f
h yperglycemia:
_ __________________________________________________________________________________
____________________________________________________________________________________________________________
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Parent category: Medical