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2022-23 Heichal Online Medical Update Form
Annual update about health conditions, medications, permission for OTC medications in school and screening exemptions. If any information here changes for your son, or if you have any questions, please email nurse@heichalhatorah.org
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* Indicates required question
Email
*
Your email
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Grade in Fall of 2022
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9TH
10TH
11TH
12TH
SINAI
Name of Parent/Guardian Completing This Form
*
Your answer
Food Allergies (if none, write "none")
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Your answer
Drug Allergies (if none, write "none")
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Your answer
Other Allergies (if none, write "none")
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Your answer
Does your child require an epi-pen and/or rescue inhaler? If yes, please explain and submit asthma and/or allergy action forms.
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Your answer
Is there any current or past history of seizure disorder?
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NO
YES, CURRENT TREATMENT
YES, PAST, NO CURRENT TREATMENT
Is there any current or past history of asthma? If current, please submit an asthma action form.
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NO
YES, CURRENT TREATMENT
YES, PAST, NO CURRENT TREATMENT
ANY CURRENT MEDICAL CONDITIONS (I.E. CROHNS, DIABETES, HYPOTHYROID, CELIAC DISEASE, AUTOIMMUNE DISORDERS, GHD, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE".
*
Your answer
ANY CURRENT OR PAST PSYCHOLOGICAL DISORDERS (I.E. ADHD, DEPRESSION, ANXIETY, EATING DISORDERS, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE".
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Your answer
HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE".
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Your answer
DOES THE STUDENT WEAR GLASSES?
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YES
NO
Has the student been diagnosed with Coronavirus (COVID-19)?
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Yes
No
If diagnosed with Coronavirus (COVID-19), was your son symptomatic?
Yes
No
Clear selection
If diagnosed with Coronavirus (COVID-19), was your son hospitalized?
Yes
No
Clear selection
Has your son been vaccinated for Covid-19? If so, please submit a copy of his vaccination card to
office@heichalhatorah.org
Yes
No
Clear selection
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE".
*
Your answer
THE FOLLOWING NON-PRESCRIPTION (aka OTC) MEDICATIONS MAY BE ADMINISTERED BY AN ADULT (NOT NECESSARILY A NURSE) IN SCHOOL, AS NEEDED, BASED ON DOSAGE, AGE, WEIGHT GUIDELINES (check as many as applicable):
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ACETAMINOPHEN (TYLENOL) FOR PAIN/FEVER
IBUPROFEN (MOTRIN, ADVIL) FOR PAIN/FEVER/INFLAMMATION/MENSTRUAL CRAMPS
CALCIUM CARBONATE (TUMS) FOR STOMACH UPSET
DIPHENHYDRAMINE (BENADRYL) FOR ALLERGIC REACTIONS
Required
NAME AND NUMBER OF PEDIATRICIAN
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Your answer
NAME AND NUMBER OF DENTIST
*
Your answer
NAME AND NUMBER OF PSYCHOLOGIST/THERAPIST, IF SEEING ONE, IF NOT PLEASE ENTER "NONE"
*
Your answer
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