MASCONOMET REGIONAL SCHOOL DISTRICT HEALTH SERVICES

20 ENDICOTT ROAD TOPSFIELD, MASSACHUSETTS 01983 (978) 887-2323

High School Ext. 6116 Fax # 978-887-7243 Middle School Ext. 6125 Fax #978-887-1991

DIABETES

To the parent/guardian of _________________________________Date of Birth _________Grade___

You have checked on school records that your child currently has diabetes. It is important to have annual health information if your child needs help at school. Please complete this form and return it tomorrow to the school nurse so a plan of care can be created for your child. It is the responsibility of parents to provide necessary special food and medicine needed at school. If you have questions, please call the school nurse.

CHECK THE SIGNS USUALLY PRESENT IN YOUR CHILD’S HYPOGLYCEMIC (LOW BLOOD SUGAR) REACTIONS:

mood changes (check the usual): ___ irritability ___ crying ___ confusion ___ inappropriate responses

headache unusually pale, moist, clammy skin drowsiness, fatigue numbness, tingling lips/tongue

shaky, nervous dizziness blurred vision loss of consciousness

other (describe) ________________________________________________________________________

___________________________________________________________________________________________________________

How often does the hypoglycemic reaction occur ?_________________________________________________

When is the usual time of day hypoglycemic reaction occurs? ________________________________________

Has hospitalization occurred in past year for the diabetes ? No Yes (when?) ________________________

Diabetes is currently being treated by Dr. _______________________________________ Phone ____________________________

¹Do blood sugar tests need to be done at school? No Yes (When : Before lunch With Symptoms Other (describe) ___________________________________________________________

If tests at school, does student need help at school with blood sugar testing? No Yes (describe)_________

__________________________________________________________________________________________

¹Do snacks need to be eaten at school? No Yes¹ mid a.m. mid p.m. other(describe)_____________________________________________________________________________

¹Does student have special needs for class parties? No Yes (describe) _________________________________________________________________________________________

¹Does student have restrictions regarding physical activity? (e.g. exercise limits) No Yes (describe)

__________________________________________________________________________________________

¹Is insulin needed at school ? No Yes (describe dose and time) ______________________________

__________________________________________________________________________________________

If yes to above, does student need help with insulin injections at school ? No Yes (describe) ___________

__________________________________________________________________________________________

¹Do ketones need to be checked at school? No Yes (action for elevated levels) _________________ __________________________________________________________________________________________

If yes to above, does student need help at school? No Yes (describe)______________________________

__________________________________________________________________________________________

PLEASE CONTINUE ON REVERSE

THE USUAL PROCEDURE FOLLOWED AT SCHOOL FOR A STUDENT’S DIABETES IS:

1. Adult will stay with student.

2. Monitor consciousness, breathing, circulation and if ordered do blood sugar/ketones testing

a. for distress, medical transport to nearest medical facility will be requested.

2. notify parents at once

3. If conscious, give a simple sugar as ½ cup fruit juice for signs of low blood sugar (may repeat times two)

a. if no improvement after third feeding, the parent is called

If your child has other specific needs, or if you have other concerns, describe here__________________________________ ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

I give my permission for the school nurse to speak with my child's PCP regarding this diagnosis and to share with necessary school personnel information included in this document  No  Yes

I give permission for the school nurse or his/her delegated personnel to administer the above medications at school or on school related events. No Yes

This student has permission to self-administer the above medication at school or on school related events, if the school nurse deems it appropriate. No Yes

Parent Signature ____________________________________________________Date __________

Student Signature ___________________________________________________Date __________

Doctor’s Signature___________________________________________________Date___________

¹Medication, tests, and activity restrictions occurring during school hours require written direction from the student’s doctor.

REMEMBER TO ADVISE THE SCHOOL IMMEDIATELY OF CHANGES IN PHONE NUMBERS, ADDRESS, RESPONSIBLE EMERGENCY CONTACT PERSON, DOCTOR, HOSPITAL PREFERENCES.

Equipment and snacks will be provided by parent.

FOR RN USE ONLY

Reviewed on : ___________________

Nursing Dx

Potential Complications:

Hypoglycemia (945) Hyperglycemia (946)

Other _____________________________________

______________________________________________

ASSIGNED STANDARD REACTION RESPONSE

INDIVIDUALIZED PLAN

Delegated or Assigned Caregiver(s)

____________________________________________________________________________________________

_{Name Date Trained}

_{__________________________________________________________________________}

R.N. Signature

Reviewed 5/2003