The National Institutes Of Health's "National Diabetes Education Program"

Blood Glucose Monitoring
Target range for blood glucose is_____ 70-150 ____70-180 ________Other
Usual times to check blood glucose _____________________________
Times to do extra blood glucose checks (check all that apply)
_______before exercise
_______after exercise
_______when student exhibits symptoms of hyperglycemia
_______when student exhibits symptoms of hypoglycemia
other (explain):_____________________________________________
Can student perform own blood glucose checks?______Yes ______No
Exceptions:__________________________________________________
Type of blood glucose meter student uses: _________________________

Insulin
Usual Lunchtime Dose
Base dose of Humalog/Novolog /Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is _____ units or does flexible dosing using _____ units/ _____ grams carbohydrate.
Use of other insulin at lunch: (circle type of insulin used): intermediate/NPH/lente _____ units or basal/Lantus/Ultralente _____ units.

Insulin Correction Doses
Parental authorization should be obtained before administering a correction dose for high blood glucose levels. ______Yes______No
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl
_____ units if blood glucose is _____ to _____ mg/dl

Can student give own injections?______Yes _____No
Can student determine correct amount of insulin?_____ Yes_____No
Can student draw correct dose of insulin?_____Yes_____No
___Parents are authorized to adjust the insulin dosage under the following circumstances:__________________________________________________

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