General Health Care Plan Form - Mukwonago Area School District - Wisconsin (2015)

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MUKWONAGO AREA SCHOOL DISTRICT—HEALTH SERVICES
CLEAR FORM
Date Received ___________
DISTRICT NURSE PHONE: 262-363-6292 X27515 FAX: 262-363-6320
Date Revised ____________
Select Year
GENERAL HEALTH CARE PLAN for
Student Name:
Health Condition:
Date of Birth:(mm/dd/yyyy)
School:
Grade:
Routine medications (at home and school)
Select One
Select One
Transportation:
Bus # __________
Car
Walk
Preferred Hospital:
Other health problems:
Location where emergency medication(s) is/are stored:
N/A
Health Office
Backpack
On Person
Locker # __________
Other ________________
Please complete specific
Health Care Plans for: Asthma / Diabetes / Seizure Disorder / Severe Allergic Reaction
See Health Assistant or District website for forms
Description of Health Condition:
Triggers related to Health Condition:
Early Signs and Symptoms & Special Instructions
Signs and Symptoms
Special Instructions
Contact Parent
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
EMERGENCY—Signs and Symptoms
Call 911 for ANY of the above EMERGENCY signs and symptoms
Remain calm!
Remain with student and send another student or staff member for help.
Clear room of other students and provide as much privacy as possible.
Call parent/guardian to inform them that 911 has been called
Other special instructions:
HEALTH CARE PROVIDER—MEDICATION ORDERS AND INSTRUCTIONS
Medication Name:
Possible Side Effects:
Frequency:
Medication Strength:
Dose:
Additional Instructions:
Health Care Provider Signature:
Date:
Phone Number (xxx-xxx-xxxx):
Fax (xxx-xxx-xxxx):
Page 1 of 2
Revised 05/13/2015 by LAH

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