Health Record Form

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HEALTH RECORD FORM
Student’s Name________________________________
NIU, Lorado Taft Campus, PO Box 299, Oregon, IL 61061
(815) 732-2111, extension 120
School________________________________________
My child will attend the Lorado Taft Field Campus from _______________________to___________________________
Date of Birth ______________ Age______ Weight _______ Male____ Female____ Cell Phone ____________________
Address___________________________________________________________________________________________
Street
City
State
Zip
Father’s work phone______________________
Name of Parent or Guardian__________________________________
Home phone ________________ Guardian’s work phone________________ Mother’s work phone________________
Alternate Contact name and number _____________________________________________________________________
Our family physician is ____________________________________Physician’s phone____________________________
The answers to these questions will be kept confidential. The purpose of these questions is to provide our nurse
with health and safety information about your child.
IMPORTANT - Please fill in date of last TETANUS BOOSTER___________________________________________
1. See back side of form if child has asthma, an Epi/Auvi-pen or doctor’s excuse from PE activities.
2. Is your child presently under a doctor's care?
______Yes ______No
3. Medical information the Taft nurse should know about. (allergy, illness, physical disability, sleep walker, bedwetter,
etc.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. SPECIAL DIET (vegetarian, diabetic, food allergies, etc.)__________________________________________________
5. MEDICATIONS -
I hereby give permission for my child to take medication at Lorado Taft Field Campus under the supervision
of authorized personnel. All medication must be brought in a container appropriately labeled by a pharmacy or physician and clearly
marked with the child's name and instructions for administering. IF YOUR CHILD IS PUT ON MEDICATION AFTER THE
HEALTH FORM IS TURNED IN--SEND A NOTE WITH NAME, INSTRUCTIONS, AND PARENT SIGNATURE.
New protocol requires a doctor’s signed medical note with exact dosages and time of day for any
subcutaneous injections, intramuscular injections or nebulizer treatments. See back side of form.
PLEASE LIST
Medication(s)
Directions for administering (specify am or pm)
________________________________________
______________________________
am
pm
________________________________________
______________________________
am
pm
________________________________________
______________________________
am
pm
Students with emergency-use inhalers, epi/auvi-pens and glucagon injections
Self-Administering Exception:
must carry them at all times.
“OVER THE COUNTER” Medications approved for student (please checkmark each type for approval):
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Anti-itch cream
Cough drops
Benadryl allergy tabs
****************************************************************************
I give permission to have my child treated by the Lorado Taft Campus nurse,
or by a physician in case of an emergency.
Signature of parent or guardian______________________________________________ Date__________________
M
EDICATIONS TO BE ADMINISTERED BY AUTHORIZED PERSONNEL SHOULD BE GIVEN TO THE
/
L
T
F
C
.
TEACHER
COORDINATOR BEFORE DEPARTURE TO ENSURE SAFE ARRIVAL AT
ORADO
AFT
IELD
AMPUS

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