Student Health And Emergency Information Form - Saint Joseph School

Student Health And Emergency Information Form - Saint Joseph School - 2016-2017 Page 2

Child Name/Grade_______________________

Please List Any Medications Your Child Takes At Home (Name, Dosage, Frequency)

_______________________________________________________________________________________

Known Allergies (Please Be Specific: Type of allergy, type of reaction, Requires Medication/Epi Pen)

________________________________________________________________________________________

Any known allergies that require a Epi Pen MUST have a physician’s order and Allergy Action Plan

To better serve your child’s medical/physical/emotional/educational/social needs, please check the

following that pertain to your child:

Heart Condition __________Diabetes_______Asthma/Inhaler__________Seizure Disorder_____________

ADD/ADHD _______Migraines _____Depression _______

Other (Specify) ____________________________________________

Does your child have hearing problems? Yes____No____ Left ear_____ Right ear_____ Hearing Aids_____

Does your child have vision problems? Yes____No____ Eyeglasses _____ Contact Lens _____

I understand that this information is confidential. However, federal law permits information in the school health

records to be shared with school officials on a “need to know” basis and with a very limited number of other

persons, including those who could help in an emergency. In other circumstances, my consent will be required.

I give permission for the exchange of information between my child’s healthcare provider and the school nurse.

Parents Signature

_____________________________________________________Date_____________________________

Student Health and Emergency Information Form Rev. 09/06/2016

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Student Health And Emergency Information Form - Saint Joseph School - 2016-2017 Page 2