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Diabetes Health History

Student Information
Name: DOB: Grade:
Father/Guardian: Phone (home): Phone (work):
Mother/Guardian: Phone (home): Phone (work):
Other Emergency Contacts
Name: Relationship: Phone:
Name: Relationship: Phone:
Physician: Phone:
Hospital: Transport: [  ] Parent   [  ] Ambulance   [  ] Other
Assessment / Daily Management
Baseline:Temp:_______   Pulse:_____   Resp:_____   BP:__________
  Ht:________   Wt:_____   Hearing:_________   Glasses/contacts:_________
  Date Diagnosed:________________   Last Hospitalization:____________________________
Type of Insulin Dose Time Given Reactions
Emergency Snacks/Medication:
Blood Sugar Checks at School:
  Equipment needed:_______________________________
  [  ] Transported daily     [  ]Stored at school
Scheduled PE/Exercise Activities: AM:
PE Modification:
Food Intake:
  Breakfast: _________________________________
  [  ] Brings own food    [  ] Selects in cafeteria    [  ] Needs assistance
  Snacks: AM _____________ PM _______________
  Brings Daily ____________________Storage _____________________
Other Health Concerns:
Additional Medications Taken:

School Nurse Signature   Date

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Last Updated: Thursday February 27, 2014 19:28:21
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