Headache Ishp - Sullivan County Department Of Education
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2SULLIVAN COUNTY DEPARTMENT OF EDUCATION
SCHOOL HEALTH SERVICES
Headache/Migraine ISHP
STUDENT
PARENT/GUARDIAN/EMERGENCY
SCHOOL YEAR
SCHOOL
GRADE
TEACHER
PHONE NUMBERS
LUNCH
PE
HEALTH CARE PROVIDER (for this health need)
NAME:
PHONE:
FAX
If student presents with this
Do this
□ Give ______________________ medication
Complains of headache
* Permission for Medication form must be completed
□ Call parent/guardian to bring medication to school (if none at school)
□ allow to rest for _______ minutes (no > 20) if necessary
Complains of headache with
□ If vomiting - call parent/guardian
□ Cool compress to head or back of neck
nausea and vomiting
□ Give ______________________ medication (if can be tolerated)
* Permission for Medication form must be completed
□ place in quiet, dark room
Light causes headache to worsen
Warning signs of headache/migraine - List
□ Call parent/guardian if no medication available or
*
no improvement in ______ minutes after giving medication.
*
*
How often does your child have headaches?
What actions are usually taken at home for these headaches?
□ NO
Does this student consult a Healthcare Professional for headaches?
□ YES
▼ Medical Provider must complete form ▼ ▼ This is the Medication form when signed by provider.▼
Medication name
Dose
Route
Frequency
Administration Instructions
Medication name
Dose
Route
Frequency
Administration Instructions
Provider Initials ____________
Signature required on the back of form
Reviewed by School Nurse (Signature)________________________________________ (Date) _______________
Reviewed by Principal or designee (Signature) ______________________________________ (Date) ___________
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