Diabetes Action Plan Form Page 2
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1
2
3
4Urine
s hould
b e
c hecked
f or
k etones
w hen
b lood
g lucose
l evel
i s
a bove
_ ________
m g/dl.
Treatment
f or
k etones:
None
P resent:
_ ____________________
Small:
_ ______________________
Moderate:
_ _______________________
Large:
_ ______________________
BLOOD
G LUCOSE
M ONITORING
Target
r ange
f or
b lood
g lucose
i s:
7 0-‐150
7 0-‐180
o ther
_ _______________
Usual
t imes
t o
c heck
b lood
g lucose:
_ _____________________________________________________________________________
Times
t o
d o
e xtra
b lood
g lucose
c hecks
( check
a ll
t hat
a pply)
b efore
e xercise
a fter
e xercise
w hen
s tudent
e xhibits
s ymptoms
o f
h yperglycemia
w hen
s tudent
e xhibits
s ymptoms
o f
h ypoglycemia
o ther
( explain)
_ ___________________________________________________________________________________________
Can
s tudent
p erform
o wn
b lood
g lucose
c hecks?
Y es
N o
Exceptions:
_ _________________________________________________________________________________________________
Type
o f
b lood
g lucose
m eter
s tudent
u ses:_________________________________________________________________________
INSULIN
Usual
M ealtime
D ose
Base
d ose
o f
r egular
H umalog/Novalog
( circle
o ne)
i nsulin
a t
b reakfast
i s
_ ___
u nits
o r
d oes
f lexible
d osing
u sing
_ ___
u nits/____
g rams
o f
c arbohydrate.
Use
o f
o ther
i nsulin
a t
b reakfast:
i ntermediate
N PH/Lente
( circle
o ne)
_ ___
u nits
o r
b asal
L antus/Ultralente
_ ___
u nits.
Base
d ose
o f
r egular
H umalog/Novalog
( circle
o ne)
i nsulin
a t
l unch
i s
_ ___
u nits
o r
d oes
f lexible
d osing
u sing
____
u nits/
_ ___
g rams
c arbohydrate.
Use
o f
o ther
i nsulin
a t
l unch:
( circle
o ne):
i ntermediate
N PH/Lente
_ ___
u nits
o r
b asal
L antus/Ultralente
_ ___
u nits.
Use
o f
o ther
i nsulin
i n
e vening:
( circle
o ne):
i ntermediate
N PH/Lente
_ ___
u nits
o r
b asal
L antus/Ultralente
_ ___
u nits.
PHYSICIAN
A UTHORIZATION
F OR
I NSULIN
A DJUSTMENT:
Parents
a re
a uthorized
t o
a djust
t he
i nsulin
d osage
u nder
t he
f ollowing
c ircumstances:
_ ___________________________________
____________________________________________________________________________________________________________
INSULIN
C ORRECTION
D OSES:
____
u nits
i f
b lood
g lucose
i s
_ ____
t o
_ ____
m g/dl
____
u nits
i f
b lood
g lucose
i s
_ ____
t o
_ ____
m g/dl
____
u nits
i f
b lood
g lucose
i s
_ ____
t o
_ ____
m g/dl
____
u nits
i f
b lood
g lucose
i s
_ ____
t o
_ ____
m g/dl
____
u nits
i f
b lood
g lucose
i s
_ ____
t o
_ ____
m g/dl
Can
s tudent
g ive
o wn
i njections?
Y es
N o
Can
s tudent
d etermine
c orrect
a mount
o f
i nsulin?
Y es
N o
Can
s tudent
d raw
c orrect
d ose
o f
i nsulin?
Y es
N o
FOR
S TUDENTS
W ITH
I NSULIN
P UMPS:
Type
o f
p ump:
_ ______________________________________________________________________________________________
Basal
r ates:
____
r ate
12
a .m.
t o
_ ___
_ ___rate
_ _____
t o
_ ___
_ ___rate
_ _____
t o
_ ___
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