Emergency Medical Authorization Form (Page 2 of 2) in pdf

Emergency Medical Authorization Form Page 2

FACTS CONCERNING THE CHILD’S MEDICAL HISTORY

TO WHICH A PHYSICIAN SHOULD BE ALERTED

Please indicate if student has had or is currently under treatment for any of the following conditions:

Give year or age when problem occurred.

_____ASTHMA

_____MENINGITIS

_____DIABETES

_____MIGRAINE HEADACHES

_____EAR/HEARING PROBLEMS:

___________

_____MUSCULAR WEAKNESS OR PARALYSIS

(type)

_____EMOTIONAL PROBLEMS:

_____________

_____BLEEDING DISORDERS:

(type)

(type)_____________

_____SEIZURES

_____HIGH BLOOD PRESSURE

_____HEART PROBLEMS:

_____INFECTIOUS DISEASES:

(type)_____________________

(type)_____________

_____HEPATITIS:

_____TETANUS SHOT:

_________________

(type)______________________________

(date)

_____OTHER: _______________________________

_____ALLERGIES?

______________________________________________________________________________________________

_____REACTIONS TO MEDICINE OR INJECTIONS? __________________________________________________

_____HOSPITALIZED FOR SERIOUS ILLNESS, SURGERY OR ACCIDENTS? _____________________________

_____USE OF CONTACT LENSES?

YES_____

NO _____

_____LONG TERM MEDICATIONS? ________________________________________________________________

_____HAVE YOU EVER BEEN INFORMED OF THE NEED TO BE ON ANTIBIOTIC THERAPY PRIOR TO DENTAL

TREATMENT? YES _____

NO _____

IF YES, IDENTIFY REQUIRED THERAPY ____________________________________________________________

_____PLEASE ADD ANY PROBLEMS NOT LISTED ___________________________________________________

Notes:

Emergency Medical Authorization Form Page 2