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