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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:_________   Allergies:____________________________________________________   Date Diagnosed:________________   Last Hospitalization:____________________________
Insulin Type of Insulin Dose Time Given Reactions
Emergency Snacks/Medication:     Instructions:
Blood Sugar Checks at School:   Equipment needed:_______________________________   [  ] Transported daily     [  ]Stored at school	Times: AM: PM:
Scheduled PE/Exercise Activities:	AM: PM: PE Modification:
Food Intake:   Breakfast: _________________________________   Lunch:_____________________________________   [  ] 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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			Jump to a new section --[ Getting Around ]-- Home Page What's New Privacy Policy Search --[ People ]-- Family Support Network Adults with Diabetes Care Photos Chat Rooms Conferences Kids with Diabetes Parents Parent Humor Scholarships and Financial Aid Grandparents Humorous Tidbits Jobs Mailing Lists CWD Forums Poetry and Art Videos Polls Quilt for Life Surveys Blogs --[ Clinic ]-- Ask the Diabetes Team Alternate Site Testing Alternative Treatments Care Suggestions CWD Español Diabetes Basics Diabetes at School 504 Plans Diabetes Camps Diabetes Dictionary Insulin Pumps Nutrition Podcasts Presentations Products Product Marketplace Sports Studies Warning Signs --[ Sources ]-- News and Information Diabetes Advocacy Links to Other Web Sites Press Releases Regional Information Services Support Groups --[ Feedback ]-- About CWD Advertise Awards Contribute Your Experiences Disclaimer Letters to the Editor Logos and Linking Share our Brochures

Last Updated: Wednesday November 26, 2003 09:44:12
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