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PATIENT DETAILS
What is the patient's first name?*
What is the patient's last name?*
What is the patient's gender?*
Patient Photo*
Toegestane bestandstypen: jpg, jpeg, gif, png, Max. bestandsgrootte: 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.
SYMPTOMS
What 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 TREATMENT
Where 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?*
Voer een nummer in van 1 tot 999.
Your country's emergency contact number?*
Voer een nummer in van 0 tot 999.
HIGH BLOOD SUGAR
What 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 ROUTINE
When does the patient need to test their blood glucose level?*
When should extra testing be performed?*
OTHER INFORMATION
If using an insulin pump would you like to add any relevant information?*
Would you like to add any relevant dietary information?*
CONTACT PERSON #1
Naam*
Phone number #1*
Phone number #2
CONTACT PERSON #2
Naam
Phone number #1
Phone number #2
SPECIAL REQUIREMENTS
Are there any special requirements that you have?
E-mail
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