2022 Medical Update and Waivers Public

Medical Update Form

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Camper Name(Required)

First Last

I confirm that my child has not been in contact with or had any communicable disease in the 10 days before camp unless noted here (e.g. COVID, chicken pox, head lice, diarrhea, impetigo, strep throat, etc.)(Required)

No, my child has not been in contact with communicable disease(s)

Yes, my child has been in contact with communicable diseases

Please explain

Has your child had COVID that you are aware of?(Required)

Yes

What date did your child have COVID?

Are there any new medical conditions or medications (since you registered) that we should know about?(Required)

Yes

Please describe these updated medical conditions and/or medications:

How active has your camper been in the last two weeks?(Required)

Not very active

Somewhat active

Very active

Unsure

How sensitive is your camper's blood glucose to activity?(Required)

Not very sensitive

Somewhat sensitive

Very sensitive

Unsure

How often has your camper been having lows in the last couple of weeks?(Required)

If your camper has lows, when do they usually happen?

Has your camper had any lows during the night in the last couple of weeks?

Yes

Unsure

How does your camper take insulin?(Required)

Injections

Pump

How does your camper monitor blood glucose?(Required)

Continuous Glucose Monitor (CGM)

Freestyle Libre

Fingerstick testing only

What devices are paired with their CGM (Libre)? Check all that apply:

Smart phone

Pump

Receiver

Data sharing with the diabetes clinic (for clinic visits)

Data sharing with parent/guardian

Would you like your camper to do a trial of a Dexcom or Libre monitor at camp?(Required)

Yes

Do you have a preference for which?(Required)

Dexcom

Libre

It doesn't matter

Do you have a smart device that you can provide your camper with?(Required)

I have access to a device for my camper

I do not have access to a device and will need a reader

Dexcom CGMs require a smart device (iOS/Android) to pair with. The device does not require cell service or data, only Bluetooth. If your camper doesn't have a smart device at camp, then we will provide you with a Libre that comes with its own reader.

How many times a day do you give insulin?(Required)

4 or more

What type of insulin does your camper currently take?(Required)

NPH

Lantus

Levemir

Basalgar

Tresiba

Tuojeo

Apidra

Fiasp

Admelog

TruRapi

Please select all that apply

Does your camper...(Required)

Use carb targets for meals

Use a sliding scale

Use a correction factor

We don't use carb targets, sliding scale, or correction factor.

Please select all that apply

When giving insulin, do you...(Required)

Give the same base dose of rapid insulin (plus a sliding scale) each day? If so, write the base dose of rapid insulin in the boxes below for each time it is given.

Use a ratio to vary the base dose of insulin according to how much is eaten. (If so, write a ratio in the boxes below as 1:x. For example, if the ratio is 10, write 1:10).

I'm unsure

NPH/N dosage information

Please fill in the details of your camper's daily NPH or N dosage.

AM Snack

Noon

PM Snack

Dinner

Bedtime

Lantus/Levemir/Basalgar/Tresiba/Tuojeo dosage information

Please fill in the details of your camper's daily Lantus/Levemir/Basalgar/Tresiba/Tuojeo dosage.

AM Snack

Noon

PM Snack

Dinner

Bedtime

NR/H/Apidra/Fiasp/Admelog/TruRapi dosage information

Please fill in the details of your camper's daily NR/H/Apidra/Fiasp/Admelog dosage.

AM Snack

Noon

PM Snack

Dinner

Bedtime

Sliding scale or ISF

Please enter your sliding scale or ISF information (for example, does it go up by 0.5 or 1 units?)

AM Snack

Noon

PM Snack

Dinner

Bedtime

Correction factor (CF) information

Please write in the number for your camper's correction factor (CF).

AM Snack

Noon

PM Snack

Dinner

Bedtime

Carb target information

Please fill in your camper's carb target information (in grams).

AM Snack

Noon

PM Snack

Dinner

Bedtime

Pump type(Required)

Medtronic 630G

Medtronic 670G

Medtronic 770G

t:slim

Omnipod

Other

Auto mode?

Yes

Basil-IQ or Control-IQ?

Basal-IQ

Control-IQ

Other

Home and camp pump patterns

Home pattern name

Camp pattern name

Please set up a new profile called “Camp”. This way, at the end of camp, you can easily change back to your usual settings if we make changes during the week. If your camper tends to be low with activity, we suggest lowering the settings by 10-20%. Otherwise, just set up a duplicate profile called camp.

Home Pump Pattern

It would be helpful for us if you would upload your pump before camp. If you do this, you do not need to fill in the table below.

Basals

Use one entry per row for time and rate of insulin, starting at midnight. If you have uploaded your pump, you do not need to fill in this section.

Click the "+" to add new lines.

Time

Rate

Ratios

Use one entry per row for time and ratios, starting at midnight. If you have uploaded your pump, you do not need to fill in this section.

Click the "+" to add new lines.

Time

Ratio

Target BG

Use one entry per row for time and target, starting at midnight. If you have uploaded your pump, you do not need to fill in this section.

Click the "+" to add new lines.

Time

Target

ISF

Use one entry per row for time and ISF, starting at midnight. If you have uploaded your pump, you do not need to fill in this section.

Click the "+" to add new lines.

Time

ISF

Have you uploaded your pump?(Required)

Yes

Not yet, but I will

No, I will not be able to do this. I have filled out the settings above

What is the name on the account that you upload pump settings to?

First Last

Signature(Required)

Please sign in this box to acknowledge you have read Camp Banting's releases and waivers.