/ Fir Acres Writing Workshop/ Diabetes: Additional Participant Information 2024

Diabetes: Additional Participant Information 2024

Health History Information: Diabetes

Since you selected “Yes” under Diabetes on the Participant Online Enrollment form, we ask that you complete this form in consultation with your participant and his/her/their physician.

Your participant will continue self-care for his/her/their diabetes while at Fir Acres. Regular Workshop staff members are not licensed medical professionals, nor are they diabetes educators. Staff will rely on information on this form to help support your participant in their self-care.

You may attach additional information as necessary, including physician orders and details about your participant’s diabetes history. Complete this form no later than May 1st.

We thank you for helping us plan your Workshop by filling out this important form. The more information we know about you before you arrive, the better your experience will be once you arrive in Portland.

If you have questions or concerns, please email (firacres@lclark.edu) or call us at 503-768-7932 and we will do our best to answer your questions.

Things to consider about the Fir Acres Writing Workshop:

Workshop staff expect that participants with diabetes are capable self-managers and that they know when to use their medication, monitor their blood sugar levels, and/or to amend any activities to support their health.
Changes in diet, schedule, and travel may make it more difficult for your participant to manage his/her diabetes while traveling to and participating in the Workshop. Our food service provider will be informed that a diabetic participant is in residence, and will work to meet participant needs. If you have any concerns about specific food offerings, please let us know.
To support participants’ self-care, we ask them to keep supplies in the Workshop office where insulin, syringes, glucometer, etc., can be stored and where a sharps container is available.
Fir Acres does not have a registered nurse in residence; the nurse is “on call” and meets with participants on registration day.
Participants may be transported if necessary to urgent care or emergency department services, approximately 15 minutes by road from campus.
Staff members will be briefed on signs that indicate high and low blood sugar levels.

All fields marked with asterisk (*) are required.

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PARTICIPANT

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Participant’s Last Name*

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Participant’s First Name*

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ADDITIONAL REQUIRED INFORMATION

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When does participant check blood sugar (BS)?*

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What is participant’s usual range of BS readings?*

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When does participant inject insulin? What type is used and how many units?*

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In addition to meals, describe participant’s pattern for snacks (e.g., time, what is eaten, etc.):*

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If a question about diabetes management comes up, who should we call and at what number?*

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LOW BLOOD SUGAR REACTIONS

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If participant’s BS gets low, what signs or behaviors should our staff expect to see?*

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If participant’s BS gets low, what should we do?*

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Are there particular stressors that tend to drop participant’s BS? What are the stressors?*

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When was participant’s last low blood sugar reaction? How often does he/she have low blood sugar reactions?*

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Has participant’s BS ever gone so low that he/she had a severe reaction (e.g., seizure, loss of consciousness)?*

Yes

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If “Yes” to the above question, please explain:

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HIGH BLOOD SUGAR QUESTIONS

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If participant’s blood sugar is running high, what signs or behaviors should our staff members note and what should participant and staff do?*

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What type of notification and how soon do you want it to occur if participant has a reaction?*

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Other participants may have questions about your participant’s diabetes care. Workshop staff tend to approach chronic health concerns by normalizing the situation rather than sensationalizing it. We encourage participants to answer questions directly from others about their health condition. Please let us know of your preference in this situation.*

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Participant’s Diabetes Care Provider:*

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Care Provider’s Phone Number:*

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What else would you like to tell us about your participant’s diabetic management plan?

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REQUIRED PARENT/GUARDIAN INFORMATION

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Name of Parent / Guardian Completing This Form*

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Parent Phone*

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Parent Email*

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Is there anything else you would like to tell us about your participant’s treatment?

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You may attach additional information about your participant’s diabetes below (letter from physician, letter from family, etc.). If we feel we need more information from you or from your participant’s physician, we will let you know. Please upload in PDF file format.

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Additional Participant Information

(50 MB max)

Link (required)

email firacres@lclark.edu

voice 503-768-7932

Director Don Waters

Administrative Coordinator Amy Baskin

Fir Acres Writing Workshop
Lewis & Clark
615 S. Palatine Hill Road MSC 58
Portland OR 97219