{"id":528,"date":"2026-09-21T10:10:27","date_gmt":"2026-09-21T14:10:27","guid":{"rendered":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/diabetes-medical-management-plan-pdf\/"},"modified":"2026-09-21T10:21:33","modified_gmt":"2026-09-21T14:21:33","slug":"diabetes-medical-management-plan-pdf","status":"publish","type":"savoy_document","link":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/diabetes-medical-management-plan-pdf\/","title":{"rendered":"Diabetes-Medical-Management-Plan.pdf"},"content":{"rendered":"<h1>Diabetes Medical Management Plan<\/h1>\n<p>School Year: ___________________________________<\/p>\n<p>Student&#8217;s Name: __________________________________ Date of Birth: ______<\/p>\n<p>Diabetes: \u25a1 Type 1  \u25a1 Type 2  Date of Diagnosis: _____<\/p>\n<p>School Name: ________________________________________ Grade: ______ Homeroom: _______________<\/p>\n<p>Plan Effective Date(s): _______________<\/p>\n<h2>Contact Information<\/h2>\n<ul>\n<li>Parent\/Guardian #1: ________________________________\n<ul>\n<li>Phone Numbers:\n<ul>\n<li>Home: ______________<\/li>\n<li>Work: ______________<\/li>\n<li>Cell\/Pager: __________<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li>Parent\/Guardian #2: ______________________________\n<ul>\n<li>Phone Numbers:\n<ul>\n<li>Home: ______________<\/li>\n<li>Work: ______________<\/li>\n<li>Cell\/Pager: __________<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li>Diabetes Healthcare Provider: _________________________\n<ul>\n<li>Phone Number: ____________________________________________________________<\/li>\n<\/ul>\n<\/li>\n<li>Other Emergency Contact: _________________________\n<ul>\n<li>Relationship: ____\n<ul>\n<li>Phone Numbers:\n<ul>\n<li>Home: _____________<\/li>\n<li>Work\/Cell\/Pager: _________<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h2>Emergency Notification<\/h2>\n<p>Notify parents of the following conditions (If unable to reach parents, call Diabetes Healthcare Provider listed above):<\/p>\n<ul>\n<li>Loss of consciousness or seizure (convulsion) immediately after Glucagon given and 911 called.<\/li>\n<li>Blood sugars in excess of ___________________ mg\/dl<\/li>\n<li>Positive urine ketones.<\/li>\n<li>Abdominal pain, nausea\/vomiting, diarrhea, fever, altered breathing, or altered level of consciousness.<\/li>\n<\/ul>\n<h2>Meals\/Snacks<\/h2>\n<p>Student can:<\/p>\n<ul>\n<li>Determine correct portions and number of carbohydrate servings<\/li>\n<li>Calculate carbohydrate grams accurately<\/li>\n<\/ul>\n<table>\n<thead>\n<tr>\n<th scope=\"col\">Time\/Location<\/th>\n<th scope=\"col\">Food Content and Amount<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td>Breakfast<\/td>\n<td>_________________<\/td>\n<\/tr>\n<tr>\n<td>Midmorning<\/td>\n<td>_________________<\/td>\n<\/tr>\n<tr>\n<td>Lunch<\/td>\n<td>_________________<\/td>\n<\/tr>\n<tr>\n<td>Mid-afternoon<\/td>\n<td>_________________<\/td>\n<\/tr>\n<tr>\n<td>Before PE\/Activity<\/td>\n<td>_________________<\/td>\n<\/tr>\n<tr>\n<td>After PE\/Activity<\/td>\n<td>_________________<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>If outside food for party or food sampling provided to class: ____________________________________________________________________<\/p>\n<h2>Blood Glucose Monitoring at School<\/h2>\n<p>Can student ordinarily perform own blood glucose checks? \u25a1 Yes \u25a1 No<\/p>\n<p>Interpret results \u25a1 Yes \u25a1 No Needs supervision? \u25a1 Yes \u25a1 No<\/p>\n<p>Time to be performed:<\/p>\n<ul>\n<li>Before breakfast<\/li>\n<li>Before PE\/Activity Time<\/li>\n<li>Midmorning: before snack<\/li>\n<li>After PE\/Activity Time<\/li>\n<li>Mid-afternoon<\/li>\n<li>Dismissal<\/li>\n<li>As needed for signs\/symptoms of low\/high blood glucose<\/li>\n<\/ul>\n<p>Place to be performed:<\/p>\n<ul>\n<li>Classroom<\/li>\n<li>Clinic\/Health Room<\/li>\n<li>Other: ________________________________<\/li>\n<\/ul>\n<p>Optional: Target Range for blood glucose: ___________ mg\/dl to __________________ (Completed by Diabetes Healthcare Provider).<\/p>\n<h2>Insulin Injections During School<\/h2>\n<p>Can student:<\/p>\n<ul>\n<li>Determine correct dose? \u25a1 Yes \u25a1 No<\/li>\n<li>Draw up correct dose? \u25a1 Yes \u25a1 No<\/li>\n<li>Give own injection? \u25a1 Yes \u25a1 No<\/li>\n<li>Needs supervision? \u25a1 Yes \u25a1 No<\/li>\n<\/ul>\n<p>Insulin Delivery:<\/p>\n<ul>\n<li>Syringe\/Vial<\/li>\n<li>Pen<\/li>\n<li>Pump (If pump worn, use &#8220;Supplemental Information Sheet for Student Wearing an Insulin Pump&#8221;)<\/li>\n<\/ul>\n<p>Standard daily insulin at school: \u25a1 Yes \u25a1 No<\/p>\n<table>\n<thead>\n<tr>\n<th scope=\"col\">Type<\/th>\n<th scope=\"col\">Dose<\/th>\n<th scope=\"col\">Time to be given<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td>__________<\/td>\n<td>_______________<\/td>\n<td>_____________________<\/td>\n<\/tr>\n<tr>\n<td>__________<\/td>\n<td>_______________<\/td>\n<td>_____________________<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Calculate insulin dose for carbohydrate intake: \u25a1 Yes \u25a1 No<\/p>\n<p>Correction dose of insulin for high blood sugar: \u25a1 Yes \u25a1 No<\/p>\n<p>If yes, use:<\/p>\n<ul>\n<li>Regular<\/li>\n<li>Humalog<\/li>\n<li>Novolog<\/li>\n<\/ul>\n<p>If yes: \u25a1 Regular \u25a1 Humalog \u25a1 Novolog Time to be given: _____<\/p>\n<p>____________# unit(s) per _________ grams Carbohydrate<\/p>\n<p>Use Formula: (BG-_______) \/ ________ = Units of insulin<\/p>\n<p>\u25a1 Add carbohydrate dose to correction dose<\/p>\n<p>If student uses a sliding scale please attach to DMMP.<\/p>\n<h2>Other Routine Diabetes Medications at School<\/h2>\n<p>\u25a1 Yes   \u25a1 No<\/p>\n<table>\n<thead>\n<tr>\n<th scope=\"col\">Name of Medication<\/th>\n<th scope=\"col\">Dose<\/th>\n<th scope=\"col\">Time<\/th>\n<th scope=\"col\">Route<\/th>\n<th scope=\"col\">Possible Side Effects<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td>_________________________________<\/td>\n<td>_____________________<\/td>\n<td>____________<\/td>\n<td>____________<\/td>\n<td>__________________<\/td>\n<\/tr>\n<tr>\n<td>_________________________________<\/td>\n<td>_____________________<\/td>\n<td>____________<\/td>\n<td>____________<\/td>\n<td>__________________<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2>Exercise, Sports, and Field Trips<\/h2>\n<p>Blood glucose monitoring and snacks as above. Quick access to sugar-free liquids, fast-acting carbohydrates, snacks, and monitoring equipment.<\/p>\n<p>A fast-acting carbohydrate such as ______________________ should be available at the site.<\/p>\n<p>Child should not exercise if blood glucose level is below ___________________________ mg\/dl OR if _____________________________________.<\/p>\n<h2>Supplies to be Furnished\/Restocked by Parent\/Guardian<\/h2>\n<ul>\n<li>Blood glucose meter\/strips\/lancets\/lancing device<\/li>\n<li>Fast-acting carbohydrate: ________________<\/li>\n<li>Insulin vials\/syringe<\/li>\n<li>Ketone testing strips<\/li>\n<li>Carbohydrate-containing snacks<\/li>\n<li>Insulin pen\/pen needles\/cartridges<\/li>\n<li>Sharps container for classroom<\/li>\n<li>Carbohydrate-free beverage\/snack<\/li>\n<li>Glucagon Emergency Kit<\/li>\n<\/ul>\n<h2>504 Testing Parameters<\/h2>\n<p>Blood Glucose should be between ___________ and __________ for school tests.<\/p>\n<h2>Management of High Blood Glucose<\/h2>\n<p>(over ______ mg\/dl)<\/p>\n<p>Usual signs\/symptoms for this student:<\/p>\n<ul>\n<li>Increased thirst, urination, appetite<\/li>\n<li>Tiredness\/sleepiness<\/li>\n<li>Blurred vision<\/li>\n<li>Warm, dry, or flushed skin<\/li>\n<li>Other: __________________________________<\/li>\n<\/ul>\n<p>Indicate treatment choices:<\/p>\n<ul>\n<li>Sugar-free fluids as tolerated: ________ mg\/dl<\/li>\n<li>Check urine ketones if blood glucose over<\/li>\n<li>Notify parent if urine ketones positive.<\/li>\n<li>May not need snack: call parent<\/li>\n<li>See &#8220;Insulin Injections: Correction Dose of Insulin for High Blood Glucose&#8221;<\/li>\n<li>Other: _________________________________________<\/li>\n<\/ul>\n<h2>Management of Very High Blood Glucose<\/h2>\n<p>(over ____________ mg\/dl)<\/p>\n<p>Usual signs\/symptoms for this student:<\/p>\n<ul>\n<li>Nausea\/vomiting<\/li>\n<li>Abdominal pain<\/li>\n<li>Rapid, shallow breathing<\/li>\n<li>Extreme thirst<\/li>\n<li>Weakness\/muscle aches<\/li>\n<li>Fruity breath odor<\/li>\n<li>Other: __________________________<\/li>\n<\/ul>\n<p>Indicate treatment choices:<\/p>\n<ul>\n<li>Carbohydrate-free fluids if tolerated<\/li>\n<li>Check urine for ketones<\/li>\n<li>Notify parents per &#8220;Emergency Notification&#8221; section<\/li>\n<li>If unable to reach parents, call diabetes care provider<\/li>\n<li>Frequent bathroom privileges<\/li>\n<li>Stay with student and document changes in status<\/li>\n<li>Delay exercise.<\/li>\n<li>Other: ______________<\/li>\n<\/ul>\n<h2>Management of Low Blood Glucose<\/h2>\n<p>(below ____________ mg\/dl)<\/p>\n<p>Usual signs\/symptoms for this child:<\/p>\n<ul>\n<li>Hunger<\/li>\n<li>Change in personality\/behavior<\/li>\n<li>Paleness<\/li>\n<li>Weakness\/shakiness<\/li>\n<li>Tiredness\/sleepiness<\/li>\n<li>Dizziness\/staggering<\/li>\n<li>Headache<\/li>\n<li>Rapid heartbeat<\/li>\n<li>Nausea\/loss of appetite<\/li>\n<li>Clamminess\/sweating<\/li>\n<li>Blurred vision<\/li>\n<li>Inattention\/confusion<\/li>\n<li>Slurred speech<\/li>\n<li>Loss of consciousness<\/li>\n<li>Seizure<\/li>\n<li>Other: ___________________________________<\/li>\n<\/ul>\n<p>Indicate treatment choices:<\/p>\n<p>If student is awake and able to swallow, give ____ grams fast-acting carbohydrate such as:<\/p>\n<ul>\n<li>4 oz. Fruit juice or non-diet soda<\/li>\n<li>3-4 glucose tablets<\/li>\n<li>Concentrated gel or tube frosting<\/li>\n<li>8 oz. Milk<\/li>\n<li>Other: ________________________<\/li>\n<\/ul>\n<p>Retest BG 10-15 minutes after treatment. Repeat treatment until blood glucose over 80 mg\/dl. Follow treatment with snack of ______________________________ if more than 1 hour till next meal\/snack or if going to activity.<\/p>\n<p>Other: _____________________________________________<\/p>\n<h2>Important<\/h2>\n<p>If student is unconscious or having a seizure, presume the student is having a low blood glucose and:<\/p>\n<ul>\n<li>Call 911 immediately and notify parents.<\/li>\n<li>Glucagon 1\/2 mg or 1 mg (circle desired dose) should be given by trained personnel.<\/li>\n<li>Glucose gel 1 tube can be administered inside cheek and massaged from outside while awaiting or during administration of Glucagon by staff member at scene.<\/li>\n<li>Glucagon\/Glucose gel could be used if student has documented low blood sugar and is vomiting or unable to swallow.<\/li>\n<\/ul>\n<p>Student should be turned on his\/her side and maintained in this &#8220;recovery&#8221; position till fully awake.<\/p>\n<h2>Signatures<\/h2>\n<p>I\/we understand that all treatments and procedures may be performed by the student and\/or trained unlicensed assistive personnel within the school or by EMS in the event of loss of consciousness or seizure. I also understand that the school is not responsible for damage, loss of equipment, or expenses utilized in these treatments and procedures. I have reviewed this information sheet and agree with the indicated instructions. This form will assist the school health personnel in developing a nursing care plan.<\/p>\n<p>Parent&#8217;s Signature: ____________________________________________________________  Date: _____________________<\/p>\n<p>Physician&#8217;s Signature: ___________________________________________________________  Date: _____________________<\/p>\n<p>School Nurse&#8217;s Signature: _______________________________________________________  Date: _____________________<\/p>\n<p>This document follows the guiding principles outlined by the American Diabetes Association.<\/p>\n<p>Revised December 5, 2003<\/p>\n","protected":false},"author":429,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-528","savoy_document","type-savoy_document","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/528","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document"}],"about":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/types\/savoy_document"}],"author":[{"embeddable":true,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/users\/429"}],"version-history":[{"count":0,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/528\/revisions"}],"wp:attachment":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/media?parent=528"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}