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Microsoft word - diabetic order form.doc


HEALTH CARE PROVIDER ORDERS FOR STUDENTS WITH DIABETES IN WASHINGTON STATE SCHOOLS
STUDENT’SNAME
____________________________Student’sbirthdate___/___/___School_____________Grade___
Emergency numbers for parents (phone) ____-_____-_____ (Cell contact 2) ____-_____-_____ (Cell) ____-_____-____
Doctor’s phone number_____-_____-______ Other contacts________________________________, _____-_____-______
HYPOGLYCEMIA (fill in individualized instructions on line or use those in parenthesis)
Unconscious--___________________________________________(phone 911) (Other orders)___________________
Blood sugar < 60 and symptomatic _______________________(juice, pop, candy) _______________________________
Blood sugar < 100 and symptomatic _______________________(crackers/cheese) _______________________________
Blood sugar < 80 and asymptomatic ______________________(feed partial meal) _______________________________
Blood sugar > 100 and symptomatic _______________________(feed partial meal)
Blood sugar at which parent should be notified–low ____________ high ___________
BLOOD SUGAR AND INSULIN DOSAGE prior to lunch (R is regular and H is lis-pro,) _____________ any other insulin requested
Blood sugar < 100
____________ units R - H - other __________________ (see hypoglycemia above) ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones) ____________ units R - H - other __________________ (check ketones)
• Licensed medical personnel allowed to give _____ units (minimum) of insulin to _____ units (maximum) of R, H, other
_________ insulin after consultation with the parent/guardian.
• Other insulin instructions (i.e., CHO counting):______________________________________________________
• If urine ketones (trace, small, moderate, large) call parents (circle one or more)

DISASTER INSULIN DOSAGE-
in case of disaster how much insulin should be given? Recommend 80% of usual dose.
A.M.
units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other units R - H - other _______________ units Lente NPH Ultralente Lantus other
STUDENT’S SELF-CARE (ability level)
Totally independent management or
student needs verification of number by staff or assist/testing to be done by school nurse 2. Student administers insulin independently or student self-injects with verification of number or student self-injects with nurse supervision or 3. Student self-treats mild hypoglycemia 4. Student monitors own snacks and meals 5. Student tests and interprets own urine ketones 6. Student tests and interprets own blood ketones
HCP _______________________________ (print/type) _________________________signature _____/_____/_____ date
Parent ______________________________ (print/type) _________________________signature _____/_____/_____ date
School Nurse _________________________ (print/type) _________________________signature _____/_____/_____ date
Start date: ____day ____mo. ____yr. Termination date: _____day _____mo. _____yr. or End of school year: _____
Must be renewed at beginning of each school year.

Source: http://www.svsd410.org/cms/lib05/WA01919490/Centricity/Domain/33/Diabetic_Order.pdf

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Kenneth Sharp, DO NEW PATIENT MEDICAL HISTORY AND QUESTIONNAIRE The information on this form is part of your confidential medical record. Please be honest with your responses. Please be advised that, for identification and part of your medical record, your photograph will be taken during your first visit. Name: ____________________________________Male / Female Date of Birth: _____/

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