Pratt Usd 382 - Student Medical Form

Pratt   U SD   3 82     -­‐   S tudent   M edical   F orm  

To   b e   c ompleted   e very   y ear   b y   p arent/guardian  

 

Student:   _ ____________________________________________________________________       G rade:   _ ____  

Date   o f   B irth:   _ __________________  

Age:   _ ______    

Sex:   _ ____   M ale     _ ____   F emale  

Family   P hysician:   _ ______________________________________________     P hone:   _ ________________________________  

Dentist:   _ _________________________________________________________       P hone:   _ ________________________________  

 

Allergies    

_____   F ood   A llergies:   _ __________________________________________________Epi   P en   R equired   _ __Yes     _ __   N o  

_____   E nvironmental   A llergies:   _ ___________________________________________________________________________  

_____   B ee   S ting   a llergy   _ _______________________________________________   E pi   P en   R equired   _ __   Y es   _ __   N o  

_____   M edication   A llergies:   _ _______________________________________________________________________________  

 

Medical   C onditions   –   B e   S pecific  

_____   D iabetes  

_____   S eizure   D isorder  

_____   A rthritis    

_____   H eart   C ondition  

_____   A DD/ADHD  

_____   G lasses/Contacts  

_____   B ladder/Bowel   p roblems    

_____   A sthma   ( mild,   p ersistent,   s evere;   T riggers)   _ ____________________________________________________  

Hearing   P roblems   –   W hich   e ar?   _ _________    

Hearing   A ids   –   W hich   e ar?   _ ______________________  

 

Other   H ealth/Medical   c onditions/concerns:   _ ______________________________________________________  

_________________________________________________________________________________________________________________  

Medications   a dministered   a t   H ome:   _ ___________________________________________________________________  

Medications   t o   b e   a dministered   a t   S CHOOL:   _ __________________________________________________________  

_________________________________________________________________________________________________________________  

Consent   T o   T reat  

In   c ase   o f   a ccident   o r   i llness,   I   h ereby   a uthorize   a   r epresentative   o f   U SD   3 82   –   P ratt   t he  

right   t o   c onsent   t o   m edical   t reatment   f or   m y   c hild.     ( Parents   w ill   b e   n otified   i n   c ase   o f  

serious   i llness   o r   i njury   a s   q uickly   a s   p ossible,   b y   s igning   t his   f orm   i t   w ill   m ake   i mmediate  

treatment   p ossible.)  

 

__________________________________________________________________  

Date   _ ____________________  

Parent/Guardian   S ignature  

 

 

Kansas   I mmunization   R ecords  

I   g ive   m y   c onsent   f or   i nformation   c ontained   o n   m y   c hild’s   K ansas   C ertificate   o f  

Immunization,   t o   b e   r eleased   t o   t he   K ansas   I mmunization   P rogram.  

 

Parent/Guardian   S ignature   _ ____________________________________________________Date   _ __________________