Health Information Form - Louisiana
ADVERTISEMENT
1
2STATE OF LOUISIANA
HEALTH INFORMATION
TO BE COMPLETED BY PARENT/LEGAL GUARDIAN EACH SCHOOL YEAR
PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE. Parent/Legal Guardian is encouraged to participate in the
development of an Individual Health Care Plan if needed. Use additional sheets, if necessary, for further explanation.
Name of School:
Grade:
Student’s Name:
Last
First
M.I.
Student’s Date of Birth:
Sex:
M
State or Country of Birth:
F
Student’s Mailing Address:
City:
State:
Zip Code:
Student’s Physical Address:
City:
State:
Zip Code:
Name of Mother or Legal
Home Phone:
Work Phone:
Cell Phone:
Employer:
Guardian:
(
)
(
)
(
)
Name of Father or Legal
Home Phone:
Work Phone:
Cell Phone:
Employer:
Guardian:
(
)
(
)
(
)
Name of child’s pediatrician or primary care provider:
Names of medical specialists or special clinics caring for your child:
____________________________________________________________________________________________________
Parent or Legal Guardian Signature
DatePART
Please check the type of health insurance your child has:
Private
Medicaid/LaCHIP
None
If your child does not have health insurance, would you like information on no cost health insurance?
Yes
No
In case of emergency—if parent or legal guardian cannot be reached—contact the following:
Name
Complete Phone Number
(
)
My child has a medical, mental, or behavioral condition that may affect his/her school day:
No
Yes (If yes,
please complete Part 2.)
Parent/Legal Guardian is responsible for providing the school
PART 2: COMPLETE ALL BOXES THAT APPLY TO YOUR CHILD.
with any medication and may be responsible for providing the school with any special food or equipment that the student will require during
the school day. Check with the school nurse to obtain correct medication and procedure forms.
❑
ALLERGIES
Allergy Type:
Food (list food(s)) _________________________________________________________
Insect sting (list insect(s)) _________________________________________________________
Medication (list medication(s)) _________________________________________________________
Other (list) __________________________________________________________________
Reactions: (Date of last occurrence if yes.)
Coughing (Date:
)
Hives (Date:
)
Rash (Date:
)
Difficulty breathing (Date:
)
Local swelling (Date:
)
Wheezing (Date:
)
Generalized swelling (Date:
)
Nausea (Date:
)
Other _________(Date:____)
Currently prescribed medications and treatments:
Oral antihistamine(Benadryl, etc.)
Epi-pen
Other ________________________
❑
ASTHMA
Triggers:
Environmental (i.e., tobacco, dust, pets, pollen, etc.) (list) _______________
Other (list) ____________
Does your child experience asthma symptoms with exercise?
No
Yes
Symptoms:
Chest tightness, discomfort, or pain
Difficulty breathing
Coughing
Wheezing
Other _________________
Currently prescribed medications and treatments: __________________________________________________________
_____________________________________________________________________________________________________
Date of last hospitalization related to asthma _____________ Date of last emergency room visit related to asthma _________
Does your child have a written asthma management plan?
No
Yes
Is peak flow monitoring used?
No
Yes
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Authorization To Release Or Obtain Health Information Form - Louisiana Department Of Health And Hospitals
Legal
Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization
Legal
Request For Access And Authorization For Use And/or Disclosure Of Protected Health Information Form - Florida Hospital Health Information Management
Business
Request For Access And Authorization For Use And/or Disclosure Of Protected Health Information Form - Florida Hospital Health Information Management
Business
Related Categories
Parent category: Medical