SD 308 Annual Health History 2022-2023

Annual Health History

2022/2023 Academic Year
School *
Student's Full Name *

First Name Middle Name Last Name
Student ID
Date of Birth *

Month Day Year
Date
Gender

Male Female Other
Grade Level (2022/2023 Academic Year) *
Name of Parent/Guardian *

First Name Last Name
Phone Number of Parent/Guardian *
Please enter a valid phone number.
Alternate Phone Number of Parent/Guardian
Please enter a valid phone number.
Physician's Name

First Name Last Name
Physician's Phone Number
Please enter a valid phone number.
Health Information

This information is shared with 911 providers in the event of an emergency
Does your student have allergies to any foods, insects, environmental allergies or other types of allergies? *

Yes No
Describe allergy, severity and any related medications:
*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 SD 308 website for you to download and print out or it 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.
Does your student have asthma? *

Yes No
Describe severity of asthma and any medications or treatments:
*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 SD 308 the website for you to download and print out or it 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.
Does your student have a seizure disorder/epilepsy? *

Yes No
What types of seizures does your student have, how do they present and what was the date of their last seizure?
*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 SD 308 website for you to download and print out it or may be picked up at the school office.
Does your student have diabetes? *

Yes No
Does your student have type I or type II diabetes? Is your student insulin dependent, and if so, does he/she use a pump and/or 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 SD 308 website for you to download and print out or it may be picked up at the school office.
Does your student have any bleeding or blood disorders? *

Yes No
Describe:
Does your student have any heart or cardiac issues? *

Yes No
Describe:
Does your student have a hearing or vision impairment? *

Yes No
Describe:
Does your student have any orthopedic concerns or impairments (bone or joint)? *

Yes No
Describe:
Does your student have any dietary restrictions? *

Yes No
Describe:
Has your student had any hospitalizations, surgeries or serious illnesses? *

Yes No
Describe:
Does your student have a shunt, history of head injuries or concussions? *

Yes No
Describe:
Does your student have any mental health concerns? *

Yes No
Describe:
Is your student currently taking any prescribed or over the counter medications? *

Yes No
Name of medication, purpose of medication, dosage and time administered:
*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 SD 308 website for you to download and print out or it may be picked up at the school office. Parents/guardians have the primary responsibility for administering medications to their students. Administering medications 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 diabetic medications.
Does your student have any additional health concerns? *

Yes No
Describe:
Electronic Authorization by Parent/Guardian *
Type first and last name
Date *

Month Day Year
Today's Date
Authorization for Emergency Medical Treatment

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 hereby 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 for 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

Zip Code
Primary Phone Number *
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Electronic Authorization by Parent/Guardian *
Type first and last name
Date *

Month Day Year
Today's Date
Authorization to Release Health Records
I hereby authorize my child's health care provider and previous school to release my child's most recent physical, immunization, and 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

Month Day Year
Today's Date
Pesticide Notification
CUSD #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 parents/guardians 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 Operations at 630-636-3190.
Should be Empty:

Annual Health History

Health Information

Authorization for Emergency Medical Treatment

Authorization to Release Health Records

Pesticide Notification