Current Health Information printable pdf download

CURRENT HEALTH INFORMATION

Complete and return ONLY if your student has medical issues potentially impacting school

Student Name ___________________________________

School _______________________________ Grade _______ Teacher___________

Guardian: _____________________ Best Number to call: _____________________

Guardian: _____________________ Best Number to call: ______________________

Check if your student has:

[ ] Bee sting allergy requiring medication or emergency treatment*

[ ] Food allergy requiring medication or emergency treatment *

[ ] Asthma requiring medication or emergency treatment*

[ ] Diabetes*

[ ] Heart Condition

[ ] Seizure Disorder

[ ] Environmental allergies

[ ] Limitations of activity or restrictions

[ ] Kidney / Urinary Problems

[ ] ADD or ADHD (circle one)

[ ] Muscle / Skeletal Problems

[ ] Vision Problems

[ ] Other Conditions (explain ________

[ ] Hearing Loss

________________________________

List Prescription Medications:

Taken daily at home ____________________________________________________

Taken daily at school ___________________________________________________

Medication Policy Summary Refer to student handbook for complete policy.

Grades K-6

All medications (prescription & non-prescription) require

completing of the Medication Authorization Form* with both physician/prescriber

and parent signature

Grades 7-12 Prescription medications require completing of the Medication

Authorization Form* with both physician/prescriber and parent/guardian

signature. Non-prescription medications may be self-administered and

require Medication Authorization Form* with only parent/guardian signature

* Contact school nurse, school office staff, or go online to District Forms for Medication

Authorization Form

If conditions develop or medications change during the year, please contact the school nurse.

Information may be shared with staff as deemed necessary by the school nurse.

Do you desire a conference with the school nurse? _____Yes _____ No

Parent/Guardian Signature __________________________________ Date _______________

Current Health Information