Medical Information Form (Page 2 of 3) in pdf

Allergies

Is your child ACUTELY allergic (hives, breathing problems, etc.) to any particular allergen (insect stings, nuts, etc.) ?

[

] No

[

] Yes

Has an EPI-PEN been prescribed for the student?

[

] No

[

] Yes. If yes, please fill out the EPI-PEN administration form.

Allergen: ______________________________

Reaction: _____________________

EPI-PEN? [ ] No [ ] Yes

Allergen: ______________________________

Reaction: _____________________

EPI-PEN? [ ] No [ ] Yes

Allergen: ______________________________

Reaction: _____________________

EPI-PEN? [ ] No [ ] Yes

Special instructions concerning allergies: (i.e. for a nut allergy; is it a severe nut allergy where the student can not even be

in contact with nuts or a severe reaction will occur.)

Medical Condition Information

Chronic Conditions: Does the student suffer from any Chronic or Ongoing Condition/s:

Special Instructions related to Chronic Conditions:

Has the student experienced any of the following?

[

] Allergies requiring an EPI-PEN

[

] Asthma requiring the use of an inhaler and/or nebulizer

[

] Chest pain/palpitations or other cardiac disorders, please list.

[

] Concussion or loss of consciousness after injury

[

] Diabetes requiring insulin

[

] Surgery or broken bones: ________________________________________________________________________________________

[

] Inability to participate in sports?

[

] Tetanus: Has student received a tetanus injection in the last year? Please list place and date: ____________

[

] Any condition that requires the administration of medication during school hours? Please elaborate:

___________________________________________________________________________________________________________________________

Please note: ANY medication to be given during school hours requires the parent/guardian and physician complete/sign

the Medication Authorization Form.

Medication Information

Medications Taken at Home