STUDENT MEDICAL HISTORY

Sweetwater City Schools
Nursing Services
School Year 2024-2025
STUDENT MEDICAL HISTORY
NAME
BIRTHDATE

MonthDayYear
Date
WEIGHT
School
Grade
TEACHER
Parent/Guardian
Ph: (H)
(W)
Cell
Emergency Contact
Phone: (Home)
Work Phone
Cell
Doctor's Name
Check the year of last complete physical?

202320222021Greater than 2 Years
Does your child have health insurance?

YesNo
Company
Please check the last year that your child went to the dentist.

202320222021Greater than 2 Years
Has your child ever had a Severe Allergic Reaction to anything that their doctor said he/she would need to have a rescue drug such as an epipen nearby if child is exposed to the allergen again?

YesNo
List Allergies and type of reaction
My child has no known allergies.

I Agree
Check any of the following diagnosed conditions that apply to your child and explain below if needed.

*Diabetes*Asthma*Cystic Fibrosis*Heart / Blood Pressure*ITPNosebleedsAnxietyADD/ADHD*Stomach / Urinary / Kidney*Muscular / OrthopedicDepressionHearing / Visually Impaired*Seizures*Sickle Cell AnemiaBipolarOther
Explanation of diagnosed conditions
List Medicines taken daily at HOME
List Medicines taken daily at SCHOOL
Medicine taken periodically within last 2 years for chronic conditions. Example - aerosol treatments:
Example : aerosol treatments
Has it been longer than 2 years since this child has had any problems or received medication related to the above checked diagnosed condition?

YesNo
If your child has one of the above diagnosed conditions, with an asterisk beside it, we will be sending you an Individual Health Plan for you and your physician to complete and turn in to the school nurse. This is the plan that schools follow if a child has a problem related to a specific diagnosis.

Only IF IT HAS BEEN GREATER THAN 2 YEARS SINCE YOUR CHILD HAS HAD ANY PROBLEMS DUE TO THIS CONDITION

AND

He / She is not on any medication to control the condition, then parent / guardian, please place your initial on the line beside the following statement, if you agree.
The school system does not need to have an Individual Health Plan on file for my child.
Initial
Parent Signature

Clear
date

MonthDayYear
Date
Student Medical History continued
Student Name
If your child has a minor injury at school, we will administer first aid. Some of the medicines / treatments used may include, but are not limited to: antibiotic ointment (used occasionally), peroxide, cortisone cream, eye wash. burn cream, etc. If you do not want us to use specific first aid medicines, please make a note of this in the space provided below this statement, stating which medicine should not be used.
In some circumstances, it may be necessary to share health information about this student with certain authorized personnel working in the school, in order to provide appropriate accommodations or health care for this student.

In case of serious illness / injury. the school will attempt to contact parents / guardian while rendering first aid. If neither the parent nor designee can be reached, the school officials are authorized to take whatever action is deemed necessary for the health of the child, including phoning 911 for transportation to the closest hospital. If your child requires a trip to the hospital, while under school supervision, we would need to share relevant health information with the providers, so that they can make the best medical care decisions for your child.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
If attempts to reach a parent / guardian have been unsuccessful. I hereby give my consent for the administration of any treatment deemed necessary by the licensed physician.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: