477 Beaverkill Road Olivebridge, New York 12461 (845) 657-8333 Ext. 15 Fax (845) 657-8489 martin.bernstein@ashokancenter.org www.ashokancenter.org 2012-13 Supplemental Health Record and Authorization for Care of Child with Insulin Dependent Diabetes Student s Name: A. For the Parent/Guardian and Physician: The Ashokan Outdoor Education Program is a fun and educational part of your school curriculum. This program involves a change from your child s normal activity routine, schedule and diet, and can present a challenge to some children with insulin-dependent diabetes. In order to make sure that your child has the best possible experience at Ashokan, please provide us with some information which will help us accommodate any needs your child may have. There should be a schedule and menu included in this packet, with details about the Ashokan Trip, such as how many hikes are planned and how long they will be, family style meals, timing between end of meals and hikes, etc. Please share this with your child s physician, and have the physician fill out the remainder of this form. In addition, we would like you or your child s physician to provide us with: Last month s blood glucose readings; three month A1C levels; and, if possible, readings from any period of time when the student may have been experiencing an activity level similar to the Ashokan Program; Any changes to the schedule, housing or meal options which you feel may be needed for the well-being of your child (i.e., protein at specific meals, timing of hikes/activities relative to meals, etc.); Your child s activity level, on a scale of 1 to 5 (1 = couch potato, 5 = very active); Orders from your physician specific to this trip (see attached information sheet); and Any other information you feel will help us design the best experience possible for your child. We will contact you after reviewing this information with any follow-up questions or requests. We invite you to send an adult free of charge to monitor your child and help to provide any support he/she may need. In any event, if during the trip your child s blood sugar becomes unstable (fluctuates outside the target range indicated by your physician), he/she may remain at Ashokan only if accompanied by a parent or other designated adult familiar with your child s condition. Please do not hesitate to contact us at the addresses and phone numbers at the top of this page if you have any questions or need more information from us. Parent/Guardian s Name: Parent/Guardian s Signature: Date Pg 1 of 5
Pg 2 of 5 Supplemental Health Record and Authorization for Care of Child with Insulin Dependent Diabetes B. For the Physician: Student s Name: The student identified on the first page of this packet is registered to attend an outdoor education program at The Ashokan Center. Please fill out this form, and provide the following: 1. A written prescription for all medications, including: dosages for insulin, insulin to carbohydrate ratio, insulin corrections, syringes, oral agents, and keto strips; 2. A medication plan and guidelines for high and low blood sugars, as well as treatment for ketoacidosis (see below); and 3. Contact numbers for a health care provider in case the student needs alternative dosing. If the student is on an insulin pump, please also provide orders: 1) for a plan for decreasing basal metabolic rate for physical activities such as a long hike, 2) and/or to remove the pump for water activities, such as canoeing, and 3) for frequency of site change, with last date of site change included. GENERAL DIABETES INFORMATION Date of diabetes diagnosis: Name of blood glucose meter child is using: 1. Does the camper carbohydrate count? Yes No Use exchanges? Yes No 2. Does the camper follow a prescribed meal plan? Yes No If yes, please indicate the total number of carbohydrates at each meal: Breakfast AM Snack Lunch PM Snack Dinner Bedtime 3. Can the camper independently: a. Carbohydrate count? Yes No b. Draw up insulin? Yes No c. Inject themselves? Yes No d. Change pump site? Yes No e. Change pump setting? Yes No Please provide details: 4. Does the camper have a history of severe hypoglycemia resulting in unconsciousness and/or seizures? If, so when was the last occurrence?
Student Name: Pg 3 of 5 5. Does the camper recognize a low blood sugar reaction? Please list reaction symptoms: 6. Has the camper ever needed glucagon in the past? If so, when? 7. Has the camper ever experienced Diabetic Ketoacidoisis (DKA)? If so, when? ACTIONS FOR LOW BLOOD SUGAR (BELOW ): 1. Provide the child with one of the following fast-acting carbohydrates in the following quantities (please delete those items which are not recommended): oz. apple or orange juice; milk, glucose tablets; fruit; Other:. 2. If lunch or snack is greater than one hour away, ALSO give the child one of the following in these quantities: # graham cracker squares; # saltines; # pieces of bread or toast; or other:. 3. Repeat blood glucose test in minutes. Repeat snack of fast-acting carbohydrates if symptoms persist or resume within minutes. 4. If the child experiences the following symptoms, and they are not eliminated by the actions specified above, contact the parent(s)/guardian(s) immediately and ask him or her to come to Ashokan to take the child to his/her physician (Please indicate the symptoms that require parental notification): Dizziness Weakness Impaired Vision Nausea/Vomiting Other:(explain) 5. If the child experiences more serious symptoms (such as loss of consciousness or seizure), Ashokan Staff will call the area's emergency personnel number (e.g. "911"). 6. Other (explain):
Student Name: Pg 4 of 5 ACTIONS FOR HIGH BLOOD SUGAR (ABOVE ): 1. Contact parent(s)/guardian(s) immediately and child's physician if blood glucose is more than 2. Other (explain): 3. Treatment for ketoacidosis: RECREATIONAL ACTIVITIES: 1. The child may participate in recreational activities. [ ] Yes [ ] No 2. Activity restrictions: [ ] None [ ] Some Restrictions (explain): 3. Please indicate any special changes made in the child s insulin when they are very active: INSULIN ORDER Method of insulin administration (please circle): Syringes Pens Inject-eze Insulin pump Brand of Insulin Used: Type of Insulin(s) Used (please circle): Regular Humalog NovoLog Apidra NPH Lantus Levemir Dose & Frequency (Coverage scale for short acting insulin doses on next page) INJECTIONS Please fill in the chart below, indicating time and dose of each insulin injection: BASAL INSULIN (Long Acting Insulin) CARBOHYDRATE TO INSULIN RATIO TYPE AMOUNT TIME TIME RATIO (unit/grams): Breakfast Lunch Dinner AM Snack PM Snack Bedtime Snack Other
Student Name: Pg 5 of 5 COVERAGE SCALES FOR INSULIN DOSES Coverage Factor If the camper uses a coverage factor, please fill out the following: Target Blood Sugar Range: Day (The # that the camper corrects BG to) Bedtime Coverage Factor(s): Sliding Scale If the camper uses a sliding scale please fill out the following: Blood Glucose Range Breakfast Lunch Dinner Bedtime INSULIN PUMPS Brand of Insulin Pump: Model of Insulin Pump: Infusion Set Used: Units used to prime: Please fill in the chart below, indicating times of basal rate and amount of bolus: BASAL CARBOHYDRATE TO INSULIN RATIO Start TIMES Stop BASAL RATE TIME RATIO (unit/grams): Breakfast Lunch Dinner AM Snack PM Snack Bedtime Snack Other Physician s Signature: Date: