Pyc Student Information Form - Columbus School For Girls Page 2
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Form:
MEDICAL HISTORY
The purpose of this section is to provide the school nurse with information regarding your daughter's current health status.
If your daughter has asthma, severe allergies, diabetes, or any other medical condition that may require special emergency
instructions for faculty and staff, please fill out a Medical/Physical Care Plan and /or the Request for Administration of
Medication form.
1) Does your child have a special health or medical condition?
No
Yes – please explain
2) Does the special health or medical condition require our faculty to perform a procedure, monitor your child for
symptoms or administer medication during the school day?
No
Yes – you must complete a Medical/Physical Care Plan and/or the Request for Administration of Medication form
3) Does your child have any food, medication or environmental allergies? (check all that apply)
No
Yes
Food
Medication
Environmental
Please list and explain:
4) Does your child's allergy/allergies require our faculty to monitor your child for symptoms, take action if a reaction
occurs, or give emergency medication to your child?
No
Yes – you must complete a Medical/Physical Care Plan and/or the Request for Administration of Medication form
5) Is your child currently using any medication or food supplement?
No
Yes – please explain
6) If yes, does this medication or food supplement need to be administered at school?
No
Yes – you must complete a Medical/Physical Care Plan and/or the Request for Administration of Medication form
7) Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
No
Yes - please explain
8) Does this dietary restriction require a modified diet?
No
Yes - written instructions from the child's health care provider must be on the Request for Administration of
Medication form.
9) List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the
staff or medical personnel in an emergency situation.
10) List any additional information about your child that would be useful for our faculty to know, such as fears, eating or
sleeping habits, or special routines. This information should not be medical or health related, as that information should be
included above.
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