Diabetes Medical Plan For School Year

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Diabetes Medical Plan for School Year 20____
Contact Information
Student:
DOB:
Diabetes Type:
1
2
Teacher:
Age:
Grade:
School:
Fax:
Phone:
Physician:
Hospital:
Guardian 1:
Relationship:
Address:
Phone:
Email:
Guardian 1:
Relationship:
Address:
Phone:
Email:
Emergency Contact:
Relationship:
Address:
Phone:
Email:
Notifications
Notify Guardians or Emergency Contact immediately if the followed occur(s)
 Nausea or Vomiting
 Loss of Consciousness
Convulsions or Seizures
 Fever
 Abdominal Pain
Diarrhea
Large Urine Ketones
 Moderate Urine Ketones
 Blood Sugars over
mg/dl
Equipment
Guardian(s) will provide the following medical equipment
 Lancets
 Urine Ketone Strips
Blood Glucose Monitor/Strips
 Sugar/Carb Source
 Glucagon Emergency Kit
Insulin Pen/Needles
Insulin Insertion Device:
Other Medication:
Dose:
Frequency:
Route:
Amount:
Monitoring
Student monitors own glucose
Student has needs a supervisor:
Time 1 Performed:
Place 1 Performed:
Time 2 Performed:
Place 2 Performed:
Time 3 Performed:
Place 3 Performed:
Time 4 Performed:
Place 4 Performed:
Low Blood Sugar
Symptoms:
Solutions:
High Blood Sugar
Symptoms:
Solutions:
Guardian Signature
Date
Teacher Signature
Date

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