Management Plan Information – A4 Home/School/WorkSite Admin2019-11-01T22:19:55+10:00 This is custom heading element Step 1 of 3 33% PATIENT DETAILSWhat is the patient's first name?* What is the patient's last name?* What is the patient's gender?*MaleFemalePatient Photo*Accepted file types: jpg, jpeg, gif, png, Max. file size: 2 MB.Please upload an image of the patient to be used as photo identification in the management plans. Please ensure that image is clear and front-facing. Files types must be one of the following: .jpg, .jpeg, .gif, .png. Please ensure file size is below 2MB.SYMPTOMSWhat blood sugar level is considered a Hypo for the patient?* What symptoms does the patient display when they are having a Hypo?* Hungry* Inability to think straight* Lack of Coordination* Drowsy* How would you summarise the patient's main symptoms when they are having a Hypo?* HYPO TREATMENTWhere will the BGL meter be at Home?* Where will the hypo kit be at Home?* Where will the BGL meter be at School/Work?* Where will the hypo kit be at School/Work?* What should the patient be given from the hypo kit?* If the patient is having a hypo and the person treating the patient cannot get to the tester or hypo kit what should they do?* If the patient shows no improvement when should they be retested?*Please enter a number from 1 to 999.Your country's emergency contact number?*Please enter a number from 0 to 999.HIGH BLOOD SUGARWhat blood glucose level is considered high for the patient?* How would you summarise the patient's main symptoms when they have a high blood glucose level?* At what blood glucose level should the patients carer/contact person be notified?* DAILY ROUTINEWhen does the patient need to test their blood glucose level?* When should extra testing be performed?* OTHER INFORMATIONIf using an insulin pump would you like to add any relevant information?*Would you like to add any relevant dietary information?*CONTACT PERSON #1Name* Phone number #1*Phone number #2CONTACT PERSON #2Name Phone number #1Phone number #2SPECIAL REQUIREMENTSAre there any special requirements that you have?PhoneThis field is for validation purposes and should be left unchanged.
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