Medical Update Form Step 1 of 2 50% HiddenEmail 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 No What date did your child have COVID?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are there any new medical conditions or medications (since you registered) that we should know about?(Required) Yes No 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 No 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 No 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) 2 3 4 or more What type of insulin does your camper currently take?(Required) NPH N Lantus Levemir Basalgar Tresiba Tuojeo NR H Apidra Fiasp Admelog TruRapi Please select all that applyDoes 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 applyWhen 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 informationPlease fill in the details of your camper's daily NPH or N dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveLantus/Levemir/Basalgar/Tresiba/Tuojeo dosage informationPlease fill in the details of your camper's daily Lantus/Levemir/Basalgar/Tresiba/Tuojeo dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveNR/H/Apidra/Fiasp/Admelog/TruRapi dosage informationPlease fill in the details of your camper's daily NR/H/Apidra/Fiasp/Admelog dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveSliding scale or ISFPlease enter your sliding scale or ISF information (for example, does it go up by 0.5 or 1 units?)AMAM SnackNoonPM SnackDinnerBedtime Add RemoveCorrection factor (CF) informationPlease write in the number for your camper's correction factor (CF).AMAM SnackNoonPM SnackDinnerBedtime Add RemoveCarb target informationPlease fill in your camper's carb target information (in grams).AMAM SnackNoonPM SnackDinnerBedtime Add RemovePump type(Required) Medtronic 630G Medtronic 670G Medtronic 770G t:slim Omnipod Other Auto mode? Yes No Basil-IQ or Control-IQ? Basal-IQ Control-IQ Other Home and camp pump patternsHome pattern nameCamp pattern name Add RemovePlease 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 PatternIt 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.BasalsUse 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.TimeRate Add RemoveRatiosUse 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.TimeRatio Add RemoveTarget BGUse 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.TimeTarget Add RemoveISFUse 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.TimeISF Add RemoveHave 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.