MCILWRAITH STATE SCHOOL
Contacts
Form E - Diabetes Management Plan
Name
School
Parents / Caregivers Names
Home Telephone
Date of Birth
Year Level
Work Telephone
Diabetes History
Name of Doctor:
Ambulance / Emergency Contact:
What form of Diabetes do you have?
How frequently do you need to monitor blood
glucose levels?
Do you self administer your blood glucose level test
and insulin injections or is assistance required?
Do you have any special needs for food or for
eating times?
How frequently do you experience hypoglycaemia
(low blood sugar)?
Please indicate your “early warning” symptoms of
hypoglycaemia?
Phone
Type 1 (Insulin Dependent)
Type 2
Sweating
Weakness
Paleness
Trembling
Irritability
Hunger
Drowsiness
Weeping
Nausea
Changes in mood
Inability to think straight
Other
Lack of coordination
Emergency Action
Additional Information:
Detailed plan of treatment provided by medical practitioner is attached
Or; Standard hypoglycaemia emergency action plan as below should be followed.
Step 1:
Commence action if the person is conscious and exhibits the symptoms above or has a blood
glucose level less than 4mmol/L
Step 2:
If the person has a fit or becomes unconscious, lay the person on their side, ensure the
airway is clear, and contact an ambulance immediately.
Step 3:
Give any one of the following:
• 80 – 100 mls Lucozage;
• 2-3 teaspoons sugar
• 4 large or 7 small jelly beans
• 125-200mls softdrink containing sugar
• 10-15g Glucose Tablets
• 2-3 teaspoons honey
• 125-200mls Fruit Juice
• 15g Oral Glucose gel
Step 4:
If symptoms have not disappeared within 10-15 minutes, repeat step 3.
Step 5:
Stay with the person and give follow up food such as milk or biscuits.
I declare that the information on this form is complete and correct and is based on advice provided by a
medical practitioner. I further request that the medication as specified on this form be administered, or
assistance be provided in the management of the medication, in accordance with the instructions
provided.
Signature: ………………………………………….…………
Relationship to student: ...……………….
Print Name: …………………………………………………..
Date: ……/……/……
Information on Education Queensland’s Information Privacy Standard can be obtained from:
http://www.iie.qld.gov.au/informationstandards
email: [email protected]