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Diabetes Forms

by Kellie Bamford

August 11, 2011

Students with diabetes are welcome to use the following form for physican Diabetic Care orders during school hours.  In addition the Medication Order form can be found on this website under medications.  Please discuss your child's plan with your School Nurse.



Andover Public Schools



Medical Management for Diabetes

To be completed by parents/school nurse and physician. (Physician must sign)


Diabetes Care Plan for                _____                                  School                                     Effective Date:              

                                             (Name of Pupil)


Date of Birth:           _________                 Age of Onset:             Grade:              Homeroom Teacher:                        

Contact Information:

Parent/guardian #1:                                                                   Address:                                                                   

            Telephone – Home:                                     Work:                                    Cell Phone:                                    

Parent/guardian #2:                                                                   Address:                                                                   

            Telephone – Home:                                     Work:                                    Cell Phone:                                    

Pupil’s Doctor/Health Care Provider:                                                                          Phone:                                    

            Nurse Educator:                                                                                                Phone:                                    

Parent designee:                                                                                         Relationship:                                           

            Telephone – Home:                                     Work:                                    Cell Phone:                                    

Hospital Choice:                                             Known Allergies:                                                 

Blood Glucose Monitoring        ___ No, will be managed at home.    Type of blood glucose meter student uses:_____________________________________________

Target range for blood glucose:  ____ mg/dl   to   ____ mg/dl                                                                                  


Times to test must be checked below:

Usual times to check blood glucose                                                   

        mid-morning                 before exercise/PE                 when student exhibits symptoms of hyperglycemia

        pre-lunch                      after exercise                          when student exhibits symptoms of hypoglycemia        

        mid-afternoon              other (explain):                                                                                                             

Can student perform own blood glucose tests?   _____ Yes   _____ No        Exceptions:                                        



Insulin       ____ No, will be managed at home. ____  Routine Insulin (supplemental on next page)


BREAKFAST – give:                                                                        LUNCH – give:

_______units     OR                                                                            _______units      OR

_______units/_______grams of carbohydrates OR                            _______units/_______grams of carbohydrates OR

_______units/_______calories                                                           _______units/_______calories

Type:                                                                        Type:                                                              


Other (e.g., pre-lunch supplemental):                                                                                                             

Can student give own injections?                                                        ___ Yes ___ No

Can student determine correct amount of insulin?                               ___ Yes ___ No

Can student draw correct dose of insulin?                                          ___ Yes ___ No

Home insulin:  Type ______________   Dose __________________  Frequency ___________________


For Students with Insulin Pumps:


Type of pump:                                                            

Insulin/carbohydrate ratio:                                         

Correction factor:                                                       


Is student competent regarding pump?  ___Yes ___No

Can student effectively troubleshoot problems (e.g.

ketosis, pump malfunction)?     ___Yes  ___No






Meals and Snacks Eaten at School  (The carbohydrate content of the food is important in maintaining a stable blood glucose level.)


                                Time                                                        Food content/amount


A.M. snack                                                                                                                                                                 


P.M. snack                                                                                                                                                                  

Other times to give snacks and content/amount:                                                                                                         




For Hypoglycemia – when blood sugar is below                     

Common symptoms:                                                                                                                                                   

Oral Treatment/Amount:                                                                                                                                            


Glucagon ordered?                No                  Yes                 1 unit (1mg)                1/2 unit (1/2 mg)         

Recheck Blood Glucose 15 minutes following oral treatment.  If blood glucose is still below 70, may repeat oral treatment and recheck blood glucose again in 15 minutes.

* If blood glucose is still below 70, repeat oral treatment and notify a parent or parent designee to pick

   up the pupil and care for him/her until blood glucose has been above 90 for at least 1 ½ hours.

* If blood glucose is above 70, follow with a protein snack.  Pupil may return to class if he/she is not

   experiencing any symptoms of hypoglycemia.

            •  Glucagon should be given if the student is unconscious, having a seizure, or is unable to


                        °  Give Glucagon (School Nurse will administer Glucagon IM; designated trained

                             school personnel will administer Glucagon SubQ).

                        °  Call 911

                        °  Notify parent or parent-designee (see page 1)

                        °  Notify physician if unable to reach parent or parent-designee (see page 1)  



For Hyperglycemia – when blood sugar is above                                (always check for ketones)

NO exercise if any ketones or if BS is >                     .    NO SPORTS/Extracurricular activities if BS is >________.  NO Sports/Extracurricular activities if ketones are present and BS is > ________.


When supplemental insulin is NOT ordered:


            A.        If blood glucose is 250 or above with ketones, encourage water.

            B.        If blood glucose is 250-300 without ketones, encourage water and mild exercise.

            C.        If blood glucose is >300, with or without ketones, encourage water.

            D.        If blood glucose is >350 encourage water.  Recheck in 60 minutes.  If level is still elevated, parent or

                        parent-designees will be notified to pick pupil up from school and care for him/her

                        until level is below 300.

            E.        Student should be sent home for glucose above  ______  and / or (circle one) _____  amt. of ketones.

When supplemental insulin is given at school:


Administer supplemental insulin when Blood Sugar is >                   


Amount of Insulin:                                                                                                                                                      




Can administration of insulin be repeated?                  Yes   If yes, frequency                                                 No

            Indications and amount:                                                                                                                                  



When supplemental insulin is given, blood sugar should be rechecked 60 minutes after insulin administration.

Student should be sent home for glucose above ________ and / or (circle one) _______amt. of ketones.


Supplies to be kept at school:                                                                                                                                                                                                                                                                                                                                                                                                                                                                

Parent comments/concerns:___________________________________________________________________


Signatures:    Please write any additional orders/comments on back  

Approved by:                                                                                                                                                 

                                              (Physician’s Signature)                                                            (date)



                                              (Physician printed name)                                                           (Phone #)


            Acknowledged/received by:                                                                                                                          


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