Peak Power Sports Individual Diabetes Care Plan (IDCP)
*For Use in Peak Power Sports After School and Sports Camps
Child's Information:
Child’s Name: ___________________________
Date of Birth: ___________________________
Parent/Guardian Names: ___________________________
Emergency Contact Numbers:
Parent/Guardian 1: ___________________________
Parent/Guardian 2: ___________________________
Alternate Contact: ___________________________
Primary Healthcare Provider: ___________________________
Provider’s Contact Information: ___________________________
Date of IDCP Creation: ___________________________
IDCP Reviewed By: ___________________________
(Parent, Coach, Healthcare Provider)
1. Diabetes Information
Type of Diabetes: (Circle one)
Type 1 Diabetes / Type 2 Diabetes / Other: ___________________________
Date of Diagnosis: ___________________________
Usual Blood Sugar Range: ___________________________
(e.g., 80-120 mg/dL)
Target Blood Sugar Range for Sports Activities: __________________________
2. Blood Sugar Monitoring
Frequency of Blood Sugar Checks During Activities:
- Before activity: ___________________________
- During activity: ___________________________
- After activity: ___________________________
Preferred Blood Glucose Meter: ___________________________
Who performs the blood sugar check?
- The child: ___________________________
- Staff/Coach assistance required: ___________________________
Symptoms of Low Blood Sugar (Hypoglycaemia) Specific to This Child:
______________________________________________________________
Symptoms of High Blood Sugar (Hyperglycaemia) Specific to This Child:
______________________________________________________________
3. Hypoglycaemia Management (Low Blood Sugar)
Symptoms to watch for:
(Check or add all that apply)
☐ Shakiness
☐ Sweating
☐ Irritability
☐ Dizziness
☐ Confusion
☐ Weakness
☐ Pale skin
☐ Other: ____________________________________________
*Treatment for Low Blood Sugar:
- Administer fast-acting glucose (e.g., juice, glucose tablets, or other):
______________________________________________________________
- Amount to give: ___________________________
- Retest blood sugar after __________ minutes.
- If blood sugar remains low, give additional: ___________________________
Rest Time Needed After Treatment:
- Minimum time before returning to play: ___________________________
Emergency Action Plan for Severe Hypoglycaemia:
- Administer glucagon: ___________________________ (Dose/Instructions)
- Call 999 and notify parents/guardians immediately.
4. Hyperglycaemia Management (High Blood Sugar)
Symptoms to watch for:
(Check or add all that apply)
☐ Increased thirst
☐ Frequent urination
☐ Fatigue
☐ Blurred vision
☐ Nausea/vomiting
☐ Other: ____________________________________________
Treatment for High Blood Sugar:
- Allow the child to drink water: ___________________________
- Monitor for worsening symptoms (e.g., rapid breathing, fruity breath, confusion).
- Retest blood sugar after __________ minutes.
- Administer additional insulin if needed (per healthcare provider’s instructions):
______________________________________________________________
Emergency Action Plan for Severe Hyperglycaemia:
- If blood sugar remains elevated or symptoms worsen, call 999 and notify parents/guardians immediately.
5. Insulin Administration
- Does the child use insulin during sports activities? (Yes / No)
- Type of insulin used: ___________________________
- Usual insulin dose: ___________________________
- Instructions for Insulin Administration:
- Before activity: ___________________________
- During activity: ___________________________
- After activity: ___________________________
- Who administers insulin?
- The child: ___________________________
- Staff/Coach assistance required: ___________________________
6. Nutrition and Snacks
- Snack Times and Frequency:
- Pre-activity snack: ___________________________
- During activity snack: ___________________________
- Post-activity snack: ___________________________
- Recommended Snacks for Treating Low Blood Sugar:
- Type and amount: ___________________________
- Special Dietary Restrictions or Preferences:
______________________________________________________________
7. Physical Activity Adjustments
Activity Modifications:
- Are there any limitations or modifications needed for physical activity?
(Yes / No) If yes, specify: ___________________________
Signs of Fatigue or Distress to Watch for During Activities:
______________________________________________________________
Procedure if Child Needs to Stop Activity Due to Blood Sugar Issues:
- Allow rest for __________ minutes.
- Retest blood sugar.
- Ensure proper hydration and nutrition.
- Notify parents if symptoms persist or worsen.
8. Emergency Contacts and Procedure
- **Primary Emergency Contact:** ___________________________ (Name & Phone)
- **Secondary Emergency Contact:** ___________________________ (Name & Phone)
- **Healthcare Provider Contact:** ___________________________ (Name & Phone)
**999 should be called if:**
- The child becomes unconscious.
- The child has a seizure.
9. Supplies Provided by Parent/Guardian
- Diabetes Supplies (e.g., glucose meter, test strips, insulin, glucagon, snacks):
______________________________________________________________
Parent/Guardian Acknowledgment:
I agree to provide the necessary diabetes supplies and update the IDCP as needed.
Parent/Guardian Signature: ___________________________
Date: ___________________________
10. Coach/Staff Acknowledgment
- Coach/Staff Responsible for Implementing This Plan:
Name: ___________________________
Acknowledgment of Responsibility:
I have read and understand the diabetes management plan for the child and will follow it as outlined.
Coach/Staff Signature: ___________________________
Date: ___________________________
This IDCP is to be updated annually or as the child’s diabetes management needs change.
Next Review Date: ___________________________