Health Care Provider Authorization And Parent/guardian Consent Form (Page 2 of 3) in pdf

Health Care Provider Authorization And Parent/guardian Consent Form Page 2

Insulin Pump Information

Type of pump: _____________________________

Basal rates: ________ 12:oo am to ________

________ ____ __ to ________

Type of insulin in pump: _____________________

Type of infusion set: _____________________

Insulin to carbohydrate ratio: _________________

Correction factor: _______________________

Is student competent/independent with pump use and maintenance? Yes or No (Parent and nurse to verify)

Can student effectively trouble shoot problems such as ketosis or pump malfunction? Yes or No

Comments:

Hypoglycemia

Usual symptoms of hypoglycemia: ________________________________________________________

Treatment of hypoglycemia: ____________________________________________________________

____________________________________________________________

Has glucagon ever been administered? Yes or No

Does the student require a regular daily snack? Yes or No If yes, what and when?__________________________

Medication Authorization for Glucagon

Medication: ______________________

Dose: ________________ Route: _____________

Indications for Use: _____________________ Possible Adverse Reactions: ________________________________

Special/ Storage Instructions: _______________________________________________________

Beginning Date:_________________

Ending Date: ____________________

Hyperglycemia

Usual symptoms of hyperglycemia: ______________________________________________________

Urine should be tested for ketones when blood glucose levels are above: ________mg/dl

Treatment of hyperglycemia: ___________________________________________________________

Health Care Provider Authorization And Parent/guardian Consent Form Page 2