Question 54
Extra information.
Put as much detail as possible in here about your child’s care needs.
Think about: taking medication, testing blood glucose and ketone levels, help with eating, carbohydrate counting, treating/identifying hypos/hypers. Pump set changes and connecting CGM.
Question 55
When did the care needs start?
Fill in as appropriate to your child.
Questions 56–64
About you.
Fill in as appropriate to you and your child.
Question 65
Extra information.
Put as much information here as you can. Include anything you have not been able to throughout the rest of the form, but don’t worry about repeating anything. Include every single detail no matter how small it may seem, from calibrating test strips to disposing of sharps.
Provide information about any healthcare professionals involved in your child’s care additional to those detailed in question 11.
List any documents you are enclosing (such as prescription lists or medical report) and whether you want them returned.
Question 66
Declaration.
Read through this and be certain you understand it. Sign and date your form and print your name.