Appendix 2
Page 1 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Pupil’s name:
Date of birth:
CHI:
Address:
Insert photograph
of pupil
School:
This Plan should be completed by the pupil’s parent/carer and approved by the hospital consultant/
specialist nurse/GP.
The parent/carer is responsible for obtaining a medical practitioner’s signature.
Once completed, the parent/carer is responsible for taking a copy of this Individual Health Care Plan
to all relevant hospital/GP appointments for updating
Appendix 2
Page 2 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Parent/Carer Contact 1
Parent/Carer Contact 2
Name:
Name:
Relationship to pupil:
Relationship to pupil:
Address:
Address:
 Home:
 Home:
 Work:
 Work:
 Mobile:
 Mobile:
Hospital/Clinic Contact(s)
General Practitioner(s)
Name:
Name:
Address:
Address:


Other Relevant Contact(s)
Name and profession:
Name and profession:
Address:
Address:


Appendix 2
Page 3 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Type 1 Diabetes – Details of Medical Condition
Underlying problem
1. Low blood sugar (Hypoglycaemia) may
result from:




not enough food (missing or delaying a
snack or meal)
extra exercise or more activity than
usual
extra exercise or more activity than
usual
too much insulin
2. High blood sugar (Hyperglycaemia) may
result from:




Details of Symptoms
Symptoms (any one or several of the following):
 headache
 blurred vision
 pale
 wobbly/shaky/weakness
 sweaty
 grumpy/bad tempered
 tearful/weepy
 feeling ‘not right’
 nausea/vomiting
 vague, non-specific symptoms
Details of Symptoms


missing an injection
poor control of diabetes
an infection
over-eating
thirst
frequency of passing urine
Details of medication:
Response
Dose
Comment
Glucose tablets
3 tablets
As per action flow chart
Glucose powder
2 teaspoons
Mixed in 10–20ml of water or sugar-free juice,
as per action flow chart
Lucozade original
50ml
As per action flow chart
Blood glucose meter
N/A
As per action flow chart
Insulin
Variable
The dose of insulin depends on blood sugar
level, amount of activity and size of meal.
Details of emergency care:
Follow instructions as per flow chart (attached).
Appendix 2
Page 4 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Action Flowchart for Hypoglycaemic Episode due to Diabetes
Pupil’s name:
Date of birth:
Insert photograph
of pupil
Hypoglycaemia (Low blood sugar of less than 4 mmol/L)
Any one or several of the following:
 headache
 blurred vision
 pale
 wobbly/shaky/weak
 sweaty
 grumpy/bad tempered
 tearful/weepy
 feeling ‘not right’
 nausea/vomiting
 non-specific symptoms
YES
Use blood glucose
meter to check blood
glucose reading.
Is the reading more
than 4mmol/L?
NO
Is the reading less
than 4mmol/L?
YES
NO
If symptoms recur or persist
recheck blood glucose level using
blood glucose meter.






Give fast acting
glucose immediately:
 3 glucose tablets
 OR 2 teaspoons of
glucose powder
 OR 50ml original
‘Lucozade’.
Allow pupil to eat 2
biscuits, as supplied
by parent/carer or,
if just before a
mean, serve their
meal as soon as
possible.
Use blood glucose
meter to recheck
blood glucose
reading.
Ensure pupil’s
hands are washed
(if possible).
Observe pupil.
Dial 999 for an ambulance.
State that the pupil has diabetes and has low
blood sugar.
Follow instructions from ambulance control
staff.
Contact parent/carer.
Stay with pupil.
If pupil is unconscious, place in recovery
position: DO NOT ATTEMPT TO GIVE
ANYTHING BY MOUTH.
After 10
minutes…
NO
YES
Is the pupil becoming
uncooperative or losing
consciousness?
Appendix 2
Page 5 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Agreement to Individual Health Care Plan
This Plan was completed on
and its contents agreed by the undersigned.
Parent/carer
I wish my child to have the medication/care detailed in this plan and I accept that the emergency
services will be summoned, as required, in the event that the school staff are unable to administer
the plan at any time where appropriate.
Name of parent/carer:
Signature:
Date:
Pupil (if appropriate)
Name of pupil:
Signature:
Date:
Medical practitioner
Name of medical practitioner:
Signature:
Date:
Date of next planned review:
(no later than 12 months from date of initial completion)
For completion by school:
CONFIRMATION OF THE SCHOOL’S AGREEMENT
I agree to the procedures detailed in this plan being administered in school. In the event that these
procedures cannot be implemented at any time the school will follow the advice received from the
health professionals in summoning the emergency services where appropriate.
Name of Head Teacher/designated person:
Signature:
Copy to be given to parent/carer.
Date:
Appendix 2
Page 6 of 6
Form 8(d): Individual Health Care Plan
Diabetes to be treated with insulin
Review Agreement Statement by Parent/Carer
Pupil’s name:
Date of birth:
I confirm that the existing Individual Health Care Plan for my child continues to reflect the current
needs of my child.
I agree therefore that the review date stated on the Plan remains applicable.
I will inform the school if my child’s needs change prior to the agreed review date.
Name of parent/carer:
Signature:
Copy to be given to parent/carer.
Date: