Diabetes Management Sheet
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1Diabetes Management Sheet
Name
Teacher
Date of birth
Grade
Age at diagnosis
Parent or Guardian
Phone
Parent of Guardian
Phone
Physician
Phone
Physician
Phone
Other contact
Phone
Treatment
Name of medication
Dose
Time
Notes
insulin
Snack
Item
Amount
Time
Notes
Monitoring
Time
Check blood sugar at
Check blood sugar at
Check blood sugar at
If blood sugar below
give the following
glucose tabs
juice
other
If blood sugar above
give the following
water
other
If blood sugar above
check ketones before exercising
The emergency glucagon kit is kept in the nurse’s office. Please consult with the nurse about
its specific location and administration.
I give the school nurse permission to communicate with child’s doctor if necessary.
Parent/Guardian
Date
Signature
Parent/Guardian
Date
Signature
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Parent category: Medical