Student Health Information Form
PLEASE COMPLETE AND RETURN THIS FORM TO MCCPS FRONT OFFICE
Contact the school nurse if you have any questions or concerns.
STUDENT NAME
*
DOB
*
ENTERING GRADE
*
Allergies
*
NONE KNOWN
YES
If yes, what allergies? (food, medications, etc)
If yes, Treatment for Allergies (if the student will need any allergy medication at school, and Allergy Emergency Care Plan signed by the physician and parent/guardian must be provided along with the medication)
Medical Conditions (heart problems, seizures, diabetes, etc.)
*
NONE KNOWN
YES
If yes, what condition?
ASTHMA
*
NONE KNOWN
YES. PLEASE HAVE THE PHYSICIAN COMPLETE AND SIGN AN ASTHMA ACTION PLAN.
If your child's asthma plan includes the use of an inhaler at school, please choose one of the following options.
My child will go to the nurse’s office where the inhaler is kept and use it under the nurse’s supervision.
I will allow my child to carry their own inhaler with the nurse's approval and the following guidelines: The student agrees never to share their inhaler with another student. The student agrees that after two puffs, if there is not marked improvement, they will go to the nurse's office immediately.
Is your child on medication?
*
NO
YES
If yes, please list medication and reason.
Glasses
*
NO
YES
For Distance
For Reading
Hearing: Any known loss or problems?
*
No
Yes
Physician's Name
*
Physician's Phone Number
*
Please enter a valid phone number.
Physician Permissions
*
I give the school nurse permission to share pertinent information about my child’s health condition with teachers, paraprofessionals, cafeteria workers, bus drivers, and field trip chaperones and to communicate via email regarding my child.
I give the school nurse permission to contact the health care provider if necessary for clarification regarding health issues, immunizations, medications, etc.
I DO NOT give consent to the school health personnel to contact the primary care physician/specialist.
The following Medications may be given to my child during school:
*
Acetaminophen (Tylenol)
Acetaminophen (Tylenol) LIQUID
Acetaminophen (Tylenol) TABLET
Ibuprofin (Advil, Motrin)
Ibuprofin (Advil, Motrin) LIQUID
Ibuprofin (Advil, Motrin) TABLET
Antacid (Tums)
Benadryl
Benadryl LIQUID
Benadryl TABLET
Do we need to contact the parent/guardian before administering the aforementioned medications?
*
Yes
No
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: