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