Annual Health Update Form
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1Brookfield Public Schools
Brookfield, CT 06804
ANNUAL HEALTH UPDATE FORM
*Please return this form to the school nurse as soon as possible*
________________________________________________Grade_____Teacher_______________
Student’s (Last Name)
(First Name)
Severe Allergy (Life threatening):
Yes
No
Neurological:
Yes No
Bee Sting
Seizure disorder
Food (explain below)
Concussion
Environmental (explain below)
Other (explain below)
Drug (explain below)
Endocrine:
Epinephrine (Epipen, Auvi-Q) required**
Diabetes
Antihistamine required**
Other (explain below)
**Medication form required annually. In
Daily Medications (list):
the absence of a nurse or on field trips,
epinephrine will be given first then 911
Respiratory:
Gastrointestinal:
Asthma
Food sensitivity/intolerance(explain below)
Inhaler needed at school**
Other (explain below)
**Medication form required annually
Other Health Concerns:
Other (explain below)
Eyes:
Contacts or eyeglasses
Explain:__________________________________________________________________________
________________________________________________________________________________
Medication Permissions
I give the school nurse my permission to administer the following medication, as authorized by the
school physician, to my child during school hours and authorized school field trips:
Center Elementary School:
Huckleberry Hill Elementary, Whisconier
Middle and Brookfield High Schools:
Acetaminophen (generic Tylenol) Yes No
Acetaminophen (generic Tylenol) Yes No
Antacid
Yes No
Throat Discomfort Relief
Yes No
Ibuprofen (Generic Advil/Motrin)
Yes No
My child has health insurance: Yes No
For information regarding HUSKY Health Plan, call 1-877-CT-HUSKY
Parent/guardian________________________ Parent/guardian____________________________
Daytime phone_________________________ Daytime phone_____________________________
Personal Physician_________________________________Phone__________________________
In case of serious injury or illness, your child will be sent to an emergency facility. The parent/guardian will be contacted
immediately and is responsible for all expenses.
Parent/guardian Signature______________________________Date________________________
6/2016
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