Diabetes supplies

Patient:
Alter:	[years]
Sex:	male   female	Weight:	[kg]
Required remedies:
Harnzuckerstreifen	Blutzuckerstreifen	Stechhilfen zur Blutentnahme	Insulin syringe 40IE 100IE pens
Alkoholtupfer	Insulin (prescription with exact brand required)	Blood-sugar-measurement-device
Collection
Presumed date of collection	am: a.m. p.m.	Name of collector:
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Imprint, http://bs.cyty.com/rosenapo/fernfahr/diabe-en.htm, Version: September, 18th 2001, jk