© 2017 Salus Education, LLC. All rights reserved.
Emergency Reference Sheet
Affix
Student Photo
Here
Student:
Date of Birth:
School Year:School:
Age:
has diabetes and takes In order to control
Weakness Shakiness Tiredness Hunger Dizziness Confusion
Pale skin SweatsCool clammy skin Clumsiness Crying IIrritability
Uncooperativeness Behavior changes Combativeness Headache Anxiety
Other:
Thirst Frequent Urination Nausea Headache Abdominal pain Sleepiness
Increased hunger Blurry vision Fruity smell on breath
Other:
Sometimes blood sugar might get too high or too low, and
might need you to call for help
blood sugar level
If (name)
blood sugar gets TOO HIGH
typically experiences the following:
Dry Mouth Vomiting
If you HAVE BEEN appropriately trained to assist the student, then perform a glucose check and follow the guidance in the
student's diabetes medical management plan if the glucose level is found to be greater than
If you HAVE NOT BEEN trained to assist, but suspect high blood sugar then
: Allow free use of the bathroom
Encourage water or sugar free fluid intake Alert the school nurse or trained personnel for assistance
If unable to reach nurse or trained personnel then contact:
or
If (name)
blood sugar gets TOO LOW
typically experiences the following:
What to do for High Blood Sugar (HYPERGLYCEMIA) DO NOT LEAVE STUDENT UNATTENDED
What to do for Low Blood Sugar (HYPOGLYCEMIA) DO NOT LEAVE STUDENT UNATTENDED
Grade:
If you HAVE BEEN appropriately trained to assist the student, then perform a glucose check and follow the
guidance in the student's diabetes medical management plan if glucose level is found to be less than:
If you HAVE NOT BEEN trained to assist, immediately contact the school nurse or trained personnel for assistance
or
If unable to reach nurse or trained personnel then contact:
Contact Information
School Nurse Name: Phone: Pager:
Other trained staff: Phone: Pager:
Physician Name: Phone: Pager:
Parent(s) Name: Phone: Pager:
Cell Phone:
Cell Phone:
Cell Phone:
Cell Phone:
Salus Education, LLC
24165 IH -10 W. Suite 217-416
San Antonio, TX 78257-1160
www.SalusEducation.com
