6. If a question about diabetes management arises, who do we call? At what number? Name of your diabetes educator _Phone number …
Questionnaire for Camper with Diabetes
Campers Name_________________________________________________________________ Date camper is coming to camp__________________________________Session __________ Date of Interview__________________________ When was your camper diagnosed with Diabetes______________________________________ About Campers Routine Diabetes Care 1 When does camper check blood sugar BS?_______________________________________ 2 What is their usual range of BS reading?__________________________________________ 3 When at what time do they regularly inject insulin?__________________________________ _____________________________________________________________________________ 4 What type is used and how many units?___________________________________________ _____________________________________________________________________________ 5 In addition to meals, describe your pattern for snacks time, what you eat, etc____________ _____________________________________________________________________________ _____________________________________________________________________________ 6 If a question about diabetes management arises, who do we call? At what number?________
_____________________________________________________________________________ About Your Reaction When Your Blood Sugar Is Low If campers BS gets low, what signs or behaviors should we expect?_______________________ _____________________________________________________________________________ _____________________________________________________________________________ If campers gets low, what should be done____________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Do certain stressors ten to drop campers BS? What are they?___________________________ _____________________________________________________________________________ _____________________________________________________________________________
When was campers last low blood sugar reaction?_____________________________________ How often does camper have low reactions?__________________________________________ Has camper ever had a severely low blood sugar reaction seizure, loss of consciousness? no yes, what happened?_____________________________________________________
_____________________________________________________________________________ _____________________________________________________________________________ Additional Information: If blood sugar is running high, what signs or behaviors would we see and what do you want us to do?__________________________________________________________________________ _____________________________________________________________________________ Who do you want us to notify if camper has a reaction? Give all phone numbers _____________________________________________________________________________ _____________________________________________________________________________ Name of your diabetes educator ___________________________________________________ Phone number___________________________________
What additional information would you like us to know?
Source:iknowdiabetes.org
