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During the youth’s stay at basketball camp, he/she will be monitored as closely as conditions permit

SLAM DUNK FOR DIABETES
(Circle which camp) DeLaSalle
Rockford
Medical Form for Children With Diabetes
MUST BE COMPLETED BY YOUR PHYSICIAN!

1. Child's Name:__________________________________________ Emergency contact phone # ___________________
2. General Health:___________________________________________________________________________________
Allergies (food, medicine, animals); if asthmatic, please indicate severity: ___________________________________
__________________________________________________________________________________________ Significant illness or disability, other than diabetes: _________________________________________________ __________________________________________________________________________________________ Medications other than insulin (with dose): ________________________________________________________ __________________________________________________________________________________________ Physical limitations:___________________________________________________________________________ Non-diabetes hospitalizations (date/diagnosis):______________________________________________________ 3. Exposure to any blood transmissible diseases: Yes ____ No ____ If so, of what nature? _________________________________________________________________________ Date ___________ Height ___________ Weight ___________ B/P ___________ Any abnormal physical findings: _______________________________________________________________ __________________________________________________________________________________________ Age of diabetes onset: ___________ Date of diagnosis: ______/______/______ Recent hospitalizations (for diabetes - list date and diagnosis): ________________________________________ __________________________________________________________________________________________ Most recent HbA1c results: Date: ______/______/______ Result: _______________ Note: It is MANDATORY that the HbA1c test must be within the last 3 months.
Current goals of diabetes management: __________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 6. Does the family adjust insulin at home? Yes ____ No ____ 7. If child is on a pump, what type? ____________________ Pump start date ________ If not currently on a pump, will the child be starting on a pump prior to the camp start date? Yes ____ No ____ 8. Is the child on a continuous glucose monitor system? CGMS? Yes _____ No ______ If yes please indicate which CGMS system patient is on: ________________________________________ 9. Insulin Usage: Please indicate sliding scale or Insulin: Carb ratio and correction bolus Baseline Sliding scale at meals:______________________________________________________ Correction factor: _______________________________ Insulin/carb ratio ___________________________ Insulin Types and Dosage – Please indicate the sliding scale, if appropriate. Brand: Lilly _____ NovoNordisk _____ Sanofi Aventis _____ Type: Novolog ____ Humalog____ Apidra_____ NPH _____ Regular _____ Lantus _____ 70/30______ 75/25________ Other ________ Meal Plan: Number of meals per day ____ Number of snacks per day ______ It is imperative that the camp medical staff be aware of any family emotional problems which may affect the child’s health at camp. Has the child or family been in counseling over the past year? Yes ____ No ____ Referred for counseling? Yes ____ No ____ If so, what is the nature of the problem? __________________________________________________________ 11. Do you have any specific suggestions for the care of your patient while at camp? __________________________________________________________________________________________ Physician/Practitioner's Signature: __________________________________________ Date: _____________________ __________________________________________, MD/DO/NP Please print/type physician/nurse practitioners name Address: ________________________________ Telephone: _______________________________ Emergency phone: _________________________ Please return to the patient’s parent or fax to 708/ 425-1193 as soon as possible.
Delay in returning this form may jeopardize the child’s application to basketball camp. Thank you for your assistance.

PARENTS: Please return completed form to Cyndee Hughes 8901 S. Major Oak Lawn IL 60453-1235 or Fax 708-425-1193

During the child’s stay at basketball camp, he/she will be monitored as closely as conditions permit. No alterations in management will be made without due consideration by the medical staff. The medical staff consists of experienced nurses and dietitians, under the supervision of a physician volunteer for the Slam Dunk for Diabetes program.

Source: http://www.slamdunkkids.net/pdf/slamdunkmed2013.pdf

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