Schhol Health Information Form (Page 2 of 2) in pdf

Check here if you want to discuss confidential information with the school nurse.

Yes

Equipment or aids used by your child: _____Glasses/Contacts _____Wheelchair ______Hearing Aid _____Crutches ____Walker

other (please list): _______________________________________________________________

Special medical procedures required by your child during the school day (nebulizer, blood sugar monitoring, tube feeding,

catheterization, etc.) These may require a doctor's order- please talk with the school nurse:

__________________________________________________________________________________________________________

Medications taken by your child may cause side effects, allergic reactions, changes in personality and other problems. Please list all

prescription, over-the-counter, and herbal medications your child is taking at Home or at School (medications at school require

written authorization from parent and doctor). Forms are available at your child’s school.

Medications taken by your

Dosage

Time(s) Taken

Taken at Home

Taken at School

Is your child covered by:

____Private Insurance

____ Medicaid

_____FAMIS

_____Has no insurance

Does your child have Dental Insurance? Yes__________ No __________

FAMIS is a state and federally funded health insurance program designed to cover children who do not qualify for Children’s

Medicaid and who do not have private health insurance. Medical, hospitalization, prescription, vision and dental services are

provided by FAMIS. If you have questions or would like to sign up for FAMIS you can call toll free 1-855-242-8282, or visit

for more information or to apply online. You may also apply at your local Department of Social Services.

Signature of Parent/Guardian completing Health Information Form:

Parent/Guardian: ______________________________________________Date: __________________________

I authorize my child’s health care provider and the school nurse to discuss my child’s health concerns and/or exchange

information pertaining to this form.

Yes

**If your child’s health condition should change, please notify the school nurse.

Revised: May 21, 2015

Schhol Health Information Form Page 2