Student Health History & Emergency Medical Treatment Consent Form

Student Health History & Emergency Medical Treatment Consent Form
School Year
Student
Address
School
Grade/Teacher
Birth Date

Month Day Year
Date
Gender
Parent/Guardian/Emergency Contacts
1st Call

Name Relationship
Area Code Phone Number
2nd Call

Name Relationship
Area Code Phone Number
3rd Call

Name Relationship
Area Code Phone Number
Student's doctor/healthcare provider:
Phone:
Insurance Information:
Group Name, ID Number, Group Number, and Subscriber
INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH ANY OF THE FOLLOWING:
If your child has a life-threatening condition, state law requires that medication and/or treatment orders from your licensed healthcare provider, and an Emergency Plan prepared by the School Nurse, must be in place before your child can attend school.
Health Condition

Indicate YES or NO
Medication Allergies
*
LIST
Food Allergies
*
List:

Food(s): dairy eggs other Does your child require an EpiPen? peanut
Rate the reaction
Allergy to Bees Stings
*
Rate the reaction
Allergies (other)
*
Asthma
*
Rate the Severity
Medications at home Medications at school
Diabetes
*
Type 1 (Insulin Dependent) Type 2
Medications at home Medications at school
Seizure Disorder
*
Seizure type Medications
Neurological Disorder
*
Specify
Heart Condition
*
Specify
Blood Disorder
*
Specify
Cancer
*
Specify
Treatment
Bowel/Bladder Issues
*
Specify
Migraine Headaches
*
Triggers
Treatment
Bone/Muscle Problems
*
Specify:
Activity Restrictions
ADD/ADHD
*
Medication for ADDIADHD:
Mental Health Behavioral Issues
*
Medications/Treatment
Wears Glasses/Contacts
*
Specify:

Glasses Contacts For Distance For Reading
Hearing Loss
*
Specify:

Hearing Loss Right Ear Hearing Loss Left Ear Hearing Aids
Other Serious Illness
*
Specify
Date of Onset:

Month Day Year
Date
Serious Injury
*
Specify
Date of Onset:

Month Day Year
Date
Surgery
*
Specify
Date(s):

Month Day Year
Date
Other Medications Taken at Home
List:
The information on this form may be shared confidentially with school staff and emergency responders as needed. In the event of a medical emergency with my child, I understand every effort will be made to inform me. If emergency care is needed, I authorize qualified professionals to provide assessment, diagnosis and any necessary emergency treatment. I understand that the school district assumes no financial liability for expenses incurred due to accident, injury and/or unforeseen circumstance.
PARENT/GUARDIAN SIGNATURE

Clear
PRINTED NAME
DATE

Month Day Year
Date
Reviewed by School Nurse:
Should be Empty:

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Student Health History & Emergency Medical Treatment Consent Form

Parent/Guardian/Emergency Contacts

Insurance Information:

INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH ANY OF THE FOLLOWING:

Health Condition

Medication Allergies

Food Allergies

Allergy to Bees Stings

Allergies (other)

Asthma

Diabetes

Seizure Disorder

Neurological Disorder

Heart Condition

Blood Disorder

Cancer

Bowel/Bladder Issues

Migraine Headaches

Bone/Muscle Problems

ADD/ADHD

Mental Health Behavioral Issues

Wears Glasses/Contacts

Hearing Loss

Other Serious Illness

Serious Injury

Surgery

Other Medications Taken at Home