Health Services

Diabetes Form

Student Diabetic History

Required

Parent or Guardian: Please complete the information below so a district nurse can provide care and create/update an Emergency Action Plan for your child.

CONTACT INFORMATION

Student's Namerequired

First Name

Last Name

Date of Birthrequired

Must contain a date in M/D/YYYY format

Schoolrequired

Graderequired

Parent/Guardian Namerequired

First Name

Last Name

Emailrequired

Best Phone Numberrequired

Text?

Yes

No

Emergency Contact Namerequired

First Name

Last Name

Emergency Contact Emailrequired

Emergency Contact Phonerequired

Text?

Yes

No

Primary Care Doctor Namerequired

First Name (optional)

Last Name

Primary Care Doctor's Clinic

Diabetes Physicianrequired

First Name (optional)

Last Name

Diabetes Physician's Clinic

Last Doctor Appointment Date

Next Doctor Appointment Date (if applicable)

DIABETES INFORMATION

When was your child diagnosed with diabetes? (Year or age)required

Diabetes Typerequired

Type 1 Diabetes

Type 2 Diabetes

Student Skill/Ability with Diabetic Carerequired

Independent

Supervised

Dependent

Hypoglycemia (Low Blood Sugar): My child's usual symptoms are:required

Hyperglycemia (High Blood Sugar): My child's usual symptoms are:required

Can your child recognize their symptoms?required

Yes

No

Sometimes

If Glucagon (injection or nasal) has ever been used, explain:

Was your child hospitalized? If so, when?

CGB (Blood Sugar Testing)required

Meter/strips or CGM (what type?)

Insulinrequired

Pen

Syringe

Pump

Insulinrequired

Pen, Syringe, Pump (what type?)

Scheduled Times for CGB (Blood Sugar Testing)

Enter all that apply.

Morning

Recess (if K-5)

Before PE

Lunch

Before Going Home

Other

Any special considerations and safety precautions for school activities?required

Consider recess, PE/sports, bus, behavior, coping, learning, functioning, etc.

During classroom parties, my child will:required

Participate by eating the treat and receive a carb bolus following carb content and physician's orders

Replace the treat with an alternate treat from home

Not eat the treat

Transportation TO Schoolrequired

Bus

Walk or Bike

Parent or carpool

Drive self

Transportation FROM Schoolrequired

Bus

Walk or Bike

Parent or carpool

Drive self

Breakfast, usuallyrequired

Hot

Cold

No breakfast at school

Lunch, usuallyrequired

Hot

Cold

If your child will participate in field trips, will a parent or guardian be available to join?required

Yes

No

Sometimes

My child won't typically attend field trips.

Parent/Guardian Signature

I understand that submitting this form electronically is the legal equivalent of my manual/handwritten signature. Submitting this form will send it to district staff, who may follow up with me for further information.

Seizure Form

Required

School records indicate that your child has a seizure disorder. Our district nurses request the following information so we may better assist your child if a seizure occurs at school. Please complete this prior to the first day of school so we can include your student's information in health care planning and trainings.

Today's Daterequired

Must contain a date in M/D/YYYY format

Student Namerequired

First Name

Last Name

Date of Birthrequired

Must contain a date in M/D/YYYY format

Graderequired

Schoolrequired

Seizure Typerequired

Approximate date of last seizure:required

How often (frequency) do seizures occur?required

Average length of time (duration) of seizures:required

What will trigger a seizure?required

List any warning signs before a seizure:

Describe the seizures:required0 / 1000

Describe student's behavior following a seizure:required0 / 1000

Neurologist Namerequired

Last Name

Neurologist Clinicrequired

Primary Care Doctorrequired

Last Name

Primary Care Clinicrequired

Emergency Seizure Medication(s): List name, dosage, and when to administer. required0 / 1000

If there is no medication, please write n/a or not applicable.

List any daily or "as needed" medications your child receives. (Include name, dosage, and time given.)required0 / 1000

If there is no medication, please write n/a or not applicable.

Note: Parents/guardians are responsible to notify a district nurse if medication or seizure information changes and provide an updated physician's note or medical statement.

Please bring all medications to school on the first day or prior. Medications need to be in their original packaging with pharmacy label and may NOT be expired. The parent/guardian (not the student) must check in all medication with the health secretary or district nurse.

Parent/Guardian Signaturerequired

I understand that submitting this form electronically is the legal equivalent of my manual/handwritten signature. Submitting this form will send it to the district staff, who may follow up with me for further information.

In This Section

Did Your Student Test Positive for COVID-19?

Too Sick for School?

Medical Forms & Information

Diabetes Form

Student Diabetic History

Parent or Guardian: Please complete the information below so a district nurse can provide care and create/update an Emergency Action Plan for your child.

CONTACT INFORMATION

DIABETES INFORMATION

Scheduled Times for CGB (Blood Sugar Testing)

Seizure Form

Seizure Form

Severe Allergy Form

Severe Allergy Form

Severe Allergy Questionnaire

If the allergy was diagnosed by skin/blood testing...

Request for Self-Administration of Medication

Request for Administration of Medication by School Personnel

Immunizations

District Nurses