Diabetes Health History Form and Management Planning Tool Diagnosis: diabetes type 1 diabetes type 2 Date of diabetes diagnosis: …


Diabetes Health History Form and Management Planning Tool

The purpose of this form is to aid the school nurse in gathering the
information necessary to develop the students Individualized Health Plan
and Emergency Action Plan

Effective Dates:
________________________________________________________________________

Students Name:
_________________________________________________________________________

Date of Birth:_________________ Known
Allergies:___________________________________________

Grade:_______________________ Homeroom Teacher:
________________________________________

Diagnosis: ? diabetes type 1 ? diabetes type 2 Date of diabetes
diagnosis: _________________

Last hospitalization/ER visit for diabetes: ____________ Has glucagon ever
been administered? ?Yes ?No

CONTACT INFORMATION
Mother/Guardian:
______________________________________________________________________

Address:____________________________________________________________________
___________

Telephone: Home _____________________Work___________________
Cell
______________________

Father/Guardian:____________________________________________________________
___________

Address:____________________________________________________________________
___________

Telephone: Home _____________________ Work___________________ Cell
______________________

Students Doctor/Health Care Provider:

Name:_______________________________________________________________________
_________

Address:____________________________________________________________________
__________

Telephone: ________________________________ Emergency Number:
__________________________

Preferred Hospital:
______________________________________________________________________

Other Emergency Contacts:
Name:_______________________________________________________________________
_________

Relationship:
__________________________________________________________________________

Telephone: Home______________________Work ___________________Cell
_____________________

Notify parents/guardian or emergency contact in the following
situations:
____________________________________________________________________________
_________

____________________________________________________________________________
_________

Diabetes Health History Form and Management Planning Tool continued

BLOOD GLUCOSE MONITORING
Target range for blood glucose is ? 70-150 ? 70-180 ? Other
________________________________
Usual times to check blood glucose
________________________________________________________
Times to do extra blood glucose check check all that apply
? before exercise
? after exercise
? when student exhibits symptoms of hyperglycemia
? when student exhibits symptoms of hypoglycemia
? other explain:
___________________________________________________________________
Can student perform own blood glucose checks? ? Yes ? No
Exceptions:
___________________________________________________________________________
Type of blood glucose meter student uses:
___________________________________________________

INSULIN
Type and dosage of insulin: _______________________________ Timing:
________________________
Type and dosage of insulin: _______________________________
Timing:
________________________
1 Can student give own injections? ? Yes ? No
2 Can student determine correct amount of insulin? ? Yes ? No
3 Can student draw correct dose of insulin? ? Yes ? No

FOR STUDENTS WITH INSULIN PUMPS
Type of pump: _______________________________ Basal rates _______ 12 am
to ______
_______ _____ to ______

_______ _____ to ______

Type of insulin in pump: _______________________ Type of infusion
set_________________________
Insulin/carbohydrate ratio: ______________________ Correction factor:
_________________________

Student Pump Abilities/Skills: Needs Assistance
Count carbohydrates ? Yes ? No
Correct bolus amount for carbohydrates consumed ? Yes ? No
Calculate and administer corrective bolus ? Yes ? No
Calculate and set basal profiles ? Yes ? No
Calculate and set temporary basal rate ? Yes ? No
Disconnect pump ? Yes ? No
Reconnect pump at infusion set ? Yes ? No
Prepare reservoir and tubing ? Yes ?
No
Insert infusion set ? Yes ? No
Troubleshoot alarms and malfunctions ? Yes ? No
Diabetes Health History Form and Management Planning Tool continued

FOR STUDENTS TAKING ORAL DIABETES MEDICATIONS

Type and dosage of medication: _______________________________ Timing:
______________________
Other medications: _________________________________________ Timing:
______________________
Other medications: _________________________________________ Timing:
______________________

MEALS AND SNACKS EATEN AT SCHOOL

Is student independent in carbohydrate calculations and management? ? Yes
? No
Meal/Snack Time Carbohydrate servings/grams
Breakfast ________________________
__________________________________
Mid-morning snack ________________________
__________________________________
Lunch ________________________
__________________________________
Mid-afternoon snack ________________________
__________________________________
Dinner ________________________
__________________________________
Snack before exercise? ? Yes ? No
Snack after exercise? ? Yes ? No
Other
times to give snacks and content/amount:
________________________________________________
Preferred snack foods:
____________________________________________________________________
Foods to avoid, if any:
____________________________________________________________________
Instructions for when food is provided to the class eg, as part of a
class party or food sampling event:
____________________________________________________________________________
___________
____________________________________________________________________________
___________

EXERCISE AND SPORTS
A fast-acting carbohydrate such as
_______________________________________________ should be
available at the site of exercise or sports
Restrictions on activity, if any:
_____________________________________________________________
Student should not exercise if blood glucose level is below _________ mg/dl
or above _________mg/dl
or if moderate to large urine ketones are present

HYPOGLYCEMIA LOW BLOOD SUGAR
Usual symptoms of hypoglycemia:
__________________________________________________________
____________________________________________________________________________
___________
Treatment of
hypoglycemia:
________________________________________________________________
____________________________________________________________________________
___________
Has glucagon ever been administered? ? Yes ? No

Diabetes Health History Form and Management Planning Tool continued

HYPERGLYCEMIA HIGH BLOOD SUGAR
Usual symptoms of hyperglycemia:
__________________________________________________________
____________________________________________________________________________
___________
Treatment of hyperglycemia:
_______________________________________________________________
____________________________________________________________________________
___________
Urine should be checked for ketones when blood glucose levels are above
_________ mg/dl
Treatment for ketones:
____________________________________________________________________

SUPPLIES TO BE KEPT AT SCHOOL
_____ Blood glucose meter, blood glucose test ______ Insulin
pump and supplies
strips, batteries for meter ______ Insulin
pen, pen needles, insulin cartridges
_____ Lancet device, lancets, gloves, etc ______ Fast-acting
source of glucose
_____ Urine ketone
strips ______ Carbohydrate containing
snack
_____ Insulin vials and syringes ______ Glucagon
emergency kit

ACKNOWLEDGED AND REVIEWED WITH:
________________________________________________
____________________________________
Students Parent/Guardian Date
________________________________________________
____________________________________
Students Parent/Guardian Date

________________________________________________
____________________________________
School Nurse Date

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Source:dhss.mo.gov

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