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Medical Questionnaire 2024-25
This form is only to be used to address medications which may be administered while the student is in attendance. Please fill out one per student, per medication.
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* Indicates required question
Email
*
Your email
Parent Name (Last, First)
*
Your answer
Emergency Contact Number (###-###-####)
*
Your answer
Student Name (Last, First)
*
Your answer
Student Grade
Your answer
Name of Medication
*
Your answer
Description of Medical Condition
*
Your answer
Please select one
*
To be taken on a regular schedule
For emergencies only
Does student self carry or self administer medication?
*
Yes
No
What are some signs and symptoms staff should understand that would warrant an emergency administration of medication?
*
Your answer
In case of emergency, which is your preferred hospital?
*
Penrose-St. Francis
UC Health Memorial
Evans U.S. Army Community
UC Health Grandview
US Health Pikes Peak Regional
No Preference
Other:
A copy of your responses will be emailed to the address you provided.
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