SD 308 Annual Health History 2020-2021

Select School *

Student ID #

Name *

First Name Last Name

Student's Middle Name: *

Birth Date: *

Month Day Year

Grade: *

Gender

Male Female

Name of Parent/ Guardian #1 *

First and Last Name

Phone Number of Parent/Guardian #1: *

Area Code Phone Number

Name of Parent/ Guardian #2

First and Last Name

Phone Number of Parent/Guardian #2:

Area Code Phone Number

Student's Physician:

Please include name and phone number

Does your child have allergies to:

Foods Insects Medications

If you answered yes to any allergies, please list the details:

Diagnosis of Asthma? *

No Yes

If yes, please indicate severity:

*Please submit an emergency action plan signed by your physician if your student has any life threatening allergies, a diagnoses of asthma and/or a medication authorization form for any medications that will be kept in the nurse’s office. If your student will be carrying their own medication, a self-administration form will need to be completed. This form is provided on the website for you to download and print out or may be picked up at the school office.

Students are not to transport medications in their possession except for the self-administration of epinephrine auto-injectors, asthma inhalers or diabetes medication.

Allergy Anaphylaxis Emergency Plan Form: https://www.sd308.org/AllergyAnaphylaxisEmergencyPlan

Asthma Action Plan Form: https://www.sd308.org/AsthmaActionPlan

Food Allergy and Anaphylaxis Emergency Care Plan Form: https://www.sd308.org/FoodAllergiesAnaphylaxisCarePlan

Birth defects? *

No Yes

Type of Birth defect(s):

Blood disorders? *

No Yes: Hemophilia Yes: Sickle Cell

Please list details of Blood disorder:

Diabetes? *

No Type 1 Type 2

Student wears:

diabetic pump continuous glucose monitor

*Please provide a diabetic care plan signed by your physician and/or a medication authorization form for any medications that will be kept in the nurse’s office. If your student will be carrying their own medication, a self-administration form will need to be completed. This form is provided on the website for you to download and print out or may be picked up at the school office.

Diabetes Medical Management Plan Form: http://www.sd308.org/DiabetesMedicalManagementPlan

History of a head injury or concussion? *

No Yes

Date of injury

Date

Diagnosis of a seizure disorder? *

No Yes

If yes indicate the type and how long the seizures usually last:

Date of last known seizure:

Date

*Please provide a seizure action plan signed by your physician and/or a medication authorization for any medications that will be kept in the nurse’s office. This form is provided on the website for you to download and print out or may be picked up at the school office.

Seizure Action Plan Form: http://www.sd308.org/SeizureActionPlan

Does student have any Heart problems? *

No Yes

If yes, please explain and include any restrictions to physical activity due to a cardiac issue:

Student has current heart murmur? *

No Yes

History of dizziness or chest pain with exercise? *

No Yes

Bone or joint problems? *

No Yes

If yes, explain:

Diagnosis of Scoliosis? *

No Yes

Please indicate any Ear/Hearing Issues: *

None Ear or Hearing Problems Has Frequent Ear Infections Has Known Hearing Loss Wears Hearing Aids

Eye or Vision Problems? *

None Student Wears Glasses Student Wears Contacts

Does student have loss of function of one or paired organs? *

No Yes

Details:

Has your student been hospitalized? *

No Yes

Date(s) of hospitalization and reason:

Has your student had surgery? *

No Yes

Date(s)of surgery and summary:

Has your student suffered a serious injury or illness? *

No Yes

Date(s) and summary of incident/illness:

Does your student have a diagnosis of migraine headaches? *

No Yes

Explain treatment used:

*Please provide a medication authorization for any medications that will be kept in the nurse’s office.

School Medication Authorization Form: http://www.sd308.org/SchoolMedicationAuthorization

Does your student have any mental health concerns? *

No Yes

Details:

May include: depression, anxiety, bipolar disorder or others

Does your student have a shunt? *

No Yes

If Yes, list the type of shunt and location of shunt on right or left side of the body:

Date of the last Dental Visit?

Date

Any dental concerns?

Please summarize any concerns

Does your student have:

Braces Dental Bridge Dental Plate

Is student currently prescribed or taking any over the counter medications on a regular basis? *

No Yes

Names of medications, when they are taken, and dosages:

*Please submit a medication authorization form for any medications that will be kept in the nurse’s office. If your student will be carrying their own medication, a self-administration form will need to be completed. This form is provided on the website for you to download and print out or may be picked up at the school office.

Parents/guardians have the primary responsibility for administering medications to their students. Administering medication during school hours or during school-related activities is discouraged unless it is necessary for the critical health and well-being of the student.

Students are not to transport medications in their possession except for the self-administration of epinephrine auto-injectors, asthma inhalers or diabetes medication.

Self Carry Medicine Form: http://www.sd308.org/SelfCarryMedForm

School Medication Authorization Form: http://www.sd308.org/SchoolMedicationAuthorization

Additional Health concerns or comments?

Electronic Authorization by Parent/Guardian *

Type First and Last Name

Date *

Date

This information is shared with 911 providers in the event of an emergency.

In the event reasonable attempts to contact me at the locations listed below are unsuccessful, I, as parent or legal guardian of:

Name of Student:

First Name Last Name

so herby authorize: (1) the treatment by a licensed medical physician of my child/ward in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, and (2) the transfer of my child/ward to any hospital reasonably accessible.

This form is completed and signed with the purpose of authorizing medical treatment under emergency circumstances in my absence.

Name of Parent/Guardian:

First Name Last Name

Relation to student:

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Phone:

Area Code Phone Number

Alternate Phone:

Area Code Phone Number

This information is shared with 911 providers in the event of an emergency.

Electronic Authorization by Parent/Guardian

First Name Last Name

Date

I hereby authorize my child's health care provider and previous school to release my child's most recent physical, immunization, an other pertinent health information for CUSD 308 for completion of student health records. This authorization is valid while the student is enrolled in CUSD 308.

Electronic Authorization by Parent/Guardian

Type First and Last Name

Date

Pesticide Notification

School District #308 practices Integrated Pest Management, a program that combines preventive techniques, non-chemical pest control methods, and the appropriate use of pesticides with a preference for products that are the least harmful to human health and the environment. The term “pesticide” includes insecticides, herbicides, rodenticides, and fungicides. Schools will notify prior to the application of pesticides through email, website posting and/or phone call.

If you have any questions or comments, please contact the Director of Buildings and Grounds at 630-636-3171.

Annual Health History

Authorization for Emergency Medical Treatment

Authorization to Release Health Records