2023-2024 Student Medical Information Form (online version)
Medical information, permission to treat, and medical history needs to be updated at the beginning of each school year.  Please use this form to update your child’s current overall health status.   It also includes a link to the current school year’s standing orders that are used when treating illness or injury.  The standing orders include common oral and topical medications that can be administered by the nurse if a child presents to the School Nurse with illness or injury.

If your student has an urgent medical concern that needs to be addressed immediately, please contact your child's school nurse by phone or email to alert them of that concern.
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Email *
Student LAST Name *
Student FIRST Name *
Student grade *
Student's Building *
Student Date of Birth *
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Homeroom
Please check all ACTIVE medical conditions for which your child is CURRENTLY being treated, taking medications, or for which a doctor monitors him/her.  (If your child has outgrown the condition or is no longer under care for that condition, please do not mark the condition in this section of the form. You will be able to provide that information in the next section.) *
Required
Please check all medical conditions for which your child has a HISTORY of being treated in the PAST, but is NO LONGER an ACTIVE diagnosis.  (i.e. Your child outgrew the condition or the condition is no longer present.)  Please DO NOT list current/active diagnoses in this section. *
Required
MEDICATION ALLERGIES: Please list all MEDICATIONS to which your student is allergic.  Please include the type of reaction (i.e. rash, swollen lips, anaphylaxis).  If your child is not allergic to any medications, please type "none". *
FOOD ALLERGIES: Please list all FOODS to which your student is allergic. Please include the type of reaction (i.e. rash, swollen lips, anaphylaxis). If your child is not allergic to any foods, please type "none". *
OTHER ALLERGIES: Please list any other allergies and the type of reaction.
Epi-pen: Is your child prescribed an Epi-pen? *
Please provide detailed information regarding any of the diagnoses or information you indicated in any of the previous sections. (For example, if you indicated your child has a cardiovascular/heart or a mental health condition, please explain the type of condition and any pertinent information the nurse/staff should know when your child is in their care.)
VISION: *
HEARING: *
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