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Microsoft word - health information form - deb will send out this year

Student Health Information
_____________ _____________ _____________ Family Doctor’s Name ____________________________________________________________________________ City ___________________________________ Phone _______________________________________ Dentist’s Name ________________________________ Date of last visit ________________________________ Optometrist’s Name ____________________________ Date of last visit ________________________________ Is your child taking any medication? Yes No Name of medication _________________________________________ Dosage of medication _______________________________________ Time it is to be taken _________________________________________ Doctor who prescribed _______________________________________ List any health problems your child may have (ADD/ADHD, constipation, migraines, allergies, asthma, seizures, diabetes, heart problems, ear infections, sore throats, tuberculosis, bladder infections, menstrual cramps, or positive ______________________________________________________________________________________________ ______________________________________________________________________________________________ List any special needs (allergy to milk, diabetic, increase fiber, low cholesterol, etc.). ______________________________________________________________________________________________ ______________________________________________________________________________________________ Describe any surgery, serious illness or injury your child had this past year. ______________________________________________________________________________________________ ______________________________________________________________________________________________ What immunization outside of school did your child __________________________________________ Immunization _____________________________________ Any Additional information pertinent to your child’s health? ______________________________________________________________________________________________ ______________________________________________________________________________________________ Please turn page over
Student Health Permission
_____________ _____________ _____________ Request for administering generic Tylenol and/or Ibuprofen in school
Medication: Acetaminophen (Generic Tylenol and/or Ibuprofen Dosage: Age & Weight Appropriate (Children under 12 will not be given Ibuprofen) Time to be given: Every 4 to 6 hours as needed Special Instructions P.O. (chewable or to swallow) Date to start: First day of school year Date to end: Last day of school year Illness or condition causing necessity for medication: minor aches & discomfort, headaches fever above 100F, or menstrual cramps Administering additional medication
Parents – Please ask you pharmacist for a second bottle with a label to send part of medicine to school. This medicine is furnished by parent or guardian in the original labeled container, including date, name and strength of the medicine and directions for use. This request must be signed by the parent or guardian to authorize giving the medication during school hours. I request the above student to be given the medication at school and school activities by qualified staff, according to the prescription or nonprescription instructions and a record maintained. The student has experienced no previous side effect from the medication. I further agree that school personnel may contact the prescriber as needed and that medication information may be shared with school personnel who need to know I understand that law provides that there shall be no liability for civil damages as result of the administration of medication where the person administering the medication acts as an ordinarily reasonably prudent person who under the same or similar circumstances. I agree to provide safe delivery of medication and equipment to and from the school and pick up remaining medication and equipment. ___________________________________________________ Below for school use only

Source: http://www.northiowa.org/reg/Health_Information_form.pdf

Doi:10.1016/s0140-6736(03)14629-6

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