Diabetes Medical Management Plan (Dmmp) Template Page 7
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7Physical activity and sports
A quick-acting source of glucose such as
glucose tabs and/or
sugar-containing juice must be available at the site
of physical education activities and sports.
Student should eat
15 grams
30 grams of carbohydrate
other: ________
before
every 30 minutes during
every 60 minutes during
after vigorous physical activity
other: ________
If most recent blood glucose is less than ______ mg/dL, student can participate in physical activity when blood glucose is
corrected and above ______ mg/dL.
Avoid physical activity when blood glucose is greater than ______ mg/dL or if urine/blood ketones are moderate to large.
(See Administer Insulin for additional information for students on insulin pumps.)
Disaster plan
To prepare for an unplanned disaster or emergency (72 hours), obtain emergency supply kit from parents/guardians.
Continue to follow orders contained in this DMMP.
Additional insulin orders as follows (e.g., dinner and nighttime): ________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________ _
Other: _____________________________________________________________________________________________
Signatures
This Diabetes Medical Management Plan has been approved by:
_____________________________________________________________________________________________________ _
Student’s Physician/Health Care Provider
Date
I, (parent/guardian) ______________________________________, give permission to the school nurse or another qualified
health care professional or trained diabetes personnel of (school) ______________________________________ to perform
and carry out the diabetes care tasks as outlined in (student) ______________________________________ Diabetes Medical
Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan
to all school staff members and other adults who have responsibility for my child and who may need to know this information
to maintain my child’s health and safety. I also give permission to the school nurse or another qualified health care professional
to contact my child’s physician/health care provider.
Acknowledged and received by:
_____________________________________________________________________________________________________ _
Student’s Parent/Guardian
Date
_____________________________________________________________________________________________________ _
Student’s Parent/Guardian
Date
_____________________________________________________________________________________________________ _
School Nurse/Other Qualified Health Care Personnel
Date
Page 7 of 7, DMMP
Tools for Effective Diabetes Management
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