Microsoft word - insulin sheets 201

INSULIN DETAIL (PARENTS)
Parents, please complete this form and
*Return form with camp application*
DYF camp, 817 South Tibbs Ave, Indianapolis, IN 46241
Fax# 317-243-4488 – If you have any questions call Dave Dozier
@ 317-224-0190 (M-F, 8A – 3P) or [email protected]
1) Circle and /or write to all that apply:
Pen(s)- Type(s)______________________________________________________ Syringe Pump-Make/Model__________________________________________ INSULINS Humalog Novolog Apidra Humulin R Novolin R Humulin N Novolin N Levemir Lantus Other:__________________________ Novolog 70/30 Novolin 70/30 Humalog 75/25 Humulin 70/30
2) If taking insulin by syringe or pen, please
complete this section:
Long acting insulin dose: Circle type (NPH / Lantus/ Levemir):
____ units in the AM
Fast acting insulin dose (Novolog/Humalog): Insulin to Carbohydrate ratio: __ unit covers ____ grams of carbs at breakfast __ unit covers ____ grams of carbs at lunch __ unit covers ____ grams of carbs at supper __ unit covers ____ grams of carbs for snacks Plus the following correction scale for blood sugars greater than target: ____-____ = add __ unit ____-____ = add __ unit ____-____ = add __ unit ____-____ = add __ unit ____-____ = add __ unit above ____= add __ unit
OR Correction Formula for high Blood Sugar: N
(Blood Sugar - _______) / ____________ =
Units of Insulin
Target Insulin Sensitivity*
EXAMPLE: (Blood Sugar - 110) / 30 = Units of Humalog
B):if your child uses different correction formulas depending on time of day,
please fill in below:
Time of Day
Blood Glucose Target Insulin Sensitivity*

*Insulin Sensitivity = “dividing number”, or how many blood sugar points will 1 unit of insulin
decrease your blood sugar.
3) If your syringe/pen insulin regimen is different
than above, then write it here:

4) If using an insulin pump, please complete this
section:
Basal Rate(s):
Start time midnight__ units/hr ___________ Start time _________ units/hr ___________ Start time _________ units/hr ___________ Start time _________ units/hr___________ Start time _________ units/hr Bolus Dosages:
Start time: midnight 1 unit of insulin per carbohydrate Start time: 1 unit of insulin per EXAMPLE: 4:00 pm 1 unit of insulin per 8 grams of carbohydrate Insulin Sensitivity/Correction Factor:
Start time: midnight 1 unit of insulin will lower blood glucose by _______mg/dl Start time: 1 unit of insulin will lower blood glucose by mg/dL Start time: 1 unit of insulin will lower blood glucose by mg/dL Start time: 1 unit of insulin will lower blood glucose by mg/dL Start time: 1 unit of insulin will lower blood glucose by mg/dL Start time: 1 unit of insulin will lower blood glucose by mg/dL EXAMPLE: 6:00 AM 1 unit of insulin will lower blood glucose by 50 mg/dl Blood Glucose Target Levels/Ranges:
Start time: from midnight target is _ Start time: from target is _ Start time: from target is _ Start time: from target is _ Start time: from target is _ EXAMPLE: from 9:00 PM target is 120-150 Active insulin: ________ hours

Source: http://www.dyfofindiana.org/INSULIN%20SHEETS%202011.pdf