Student Health Record Form
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Big Sky
Hellgate
STUDENT HEALTH RECORD
Graduation
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Sentinel
Seeley Swan
Missoula County Public Schools
Year:
Student’s Name: ____________________________________________ Sex: ________ Birthdate: ______________________
Last
First
Middle
Student’s Address: __________________________________________________ Home Phone: ________________________
Father’s Name: _____________________________________________________ Work Phone: ________________________
Last
First
Mother’s Name: _____________________________________________________ Work Phone: ________________________
Last
First
Legal Guardian’s Name: ______________________________________________ Phone: _____________________________
Name: ________________________________Phone: _____________________
In case of accident or emergency, contact:
Name: ________________________________Phone: _____________________
In the case of accident or serious illness, the school will provide first aid and contact the parents to obtain further medical attention. The
school may notify emergency services if deemed necessary. If appropriate and the school is unable to contact the parent, the school may
contact the medical provider listed below and follow his/her instructions.
Physician: _______________________________________________ Phone: ___________________________
Hospital Preference: ___________________________
Student Health History
The information that you provide about your child’s health conditions may be disclosed to school staff to
ensure your child’s health, safety and accommodations as needed.
□ Allergies: To what? (Medicines, food, etc) _______________________________________________________________
Symptoms your child had: ____________________________________________________________________________
What medications were used to treat those symptoms? _____________________________________________________
Has your child ever been given a written prescription for epinephrine (Epipen)? Yes *
No
□ Asthma OR Reactive Airway Disease:
What “triggers” or causes asthma symptoms in your child?
□ Exercise □ Respiratory infection
□ Change in temperature □ Animals
□ Foods__________________________
□ Strong odors or fumes □ Dust
□ Pollens □ Molds □ Carpets in rooms □ Other __________________________
Daily Asthma Medications: ___________________________________________________________________________
Emergency Asthma medications: ______________________________________________________________________
□ Diabetes: Type: _____________ Medications: _________________________________________□ Pump □ Injections
□ Seizures: Type: _____________________________________________ Date of last seizure: ________________________
Current anti-seizure medications: ______________________________________________________________________
□ Heart Condition: _____________________________________________________________________________________
□ Birth defects: _______________________________________________________________________________________
□ Injuries: ____________________________________________________________________________________________
□ Other: ______________________________________________________________________________________________
Physical restrictions, health problems or medication at home that may require special consideration:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
NO MEDICATION, OVER THE COUNTER OR PRESCRIPTION, WILL BE ADMINSITERED WITHOUT
PROPER PHYSICIAN /PARENT SIGNATURES. See school nurse for form
X
Date: _________________
______________________________________________________________
Parent/ Legal Guardian signature
Revised 12/10/2010
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