To whom it may concern:

has diabetes (type 1 diabetes, Insulin-dependent diabetes mellitus). He/She needs insulin injections and blood glucose tests everyday. His/Her 3 meals and snacks must be provided as schedule. We appreciate your kind assistance. The following is his/her clinical summary.

Diagnosis: 250.01 Type 1 Diabetes (Insulin-dependent diabetes

mellitus)

Date of Diagnosis:

Date of Birth:

Current Insulin Regimen

Brands of Insulins:

Long-acting:

Intermediate-acting:

Short-acting:

Rapid-acting:

Mixed:

Dose (Units) of Insulins

Other Medications Pertinent Laboratory Data

Hba1c: % ( / /20 )

Precautions which need to be taken

He/She must carry insulin, syringes, glucometer, lancets, alcohol swabs and Glucagon.

Visiting Staff

Division of Pediatric Endocrinology

Departments of Pediatrics, Mackay Memorial Hospital 92, Section 2, Chung-San N Rd, Taipei, 10449 Taiwan Taipei

Telephone: 886-2-25433535

Fax: 886-2-25433642

敬愛的長官:

患有糖尿病 (第 1 型糖尿病)。他/她必須每天注射胰島素治療和監測血糖。他/她的三餐和 點心要按預定時間供應，以確保血糖穩定和身體健康。我們感謝您的親切幫助。下述是他/她的臨床資料。

診斷: 250.01 Type 1 Diabetes (Insulin-dependent diabetes mellitus)

確診日期：出生日期：

目前胰島素處方

胰島素品名

長效型：中效型：短效型：速效型：混合型：

劑量(單位, unit)

其他藥劑

有關的檢驗結果

糖化血色素 (Hba1c): % ( / /20 )

注意事項

必須隨身擕帶胰島素、注射針、血糖機、採血針、酒精棉和昇糖素

馬偕紀念醫院 小兒科部 小兒內分泌科主治醫師電話 02-25433535, 傳真 02-25433642