Health & Medical Information

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Please provide the following information in regards to the health and wellness of your child.

电子邮件地址 *

Name of Student

Any Allergies? *

None

Bee Stings

Wasp Stings

Food Allergies

Environment

Latex

Medications

其他:

必填

Describe any reactions to look for and how to intervene.

List of Medications and what they are for.

If your child takes medication, do they take the medication at home? Or do they need to take it at school?

At Home

At School

N/A

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Asthma? *

Yes

Attention Deficit Disorder? *

Yes

Diabetes? *

Yes

If yes to diabetes, are they insulin dependent/needs school program set up? Or do they self manage (snacks, diet, testing, coverage)?

Insulin dependent/Needs school program set up

Self manages snacks, diet, testing and coverage

其他:

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Headaches? *

Yes

If yes to headaches, which medication works best for them?

Seizures? *

Yes

If yes to seizures, do they need medication at school, they take it at home, or are they not currently on medication?

They need medication at school.

They take the medication at home.

They have a history of seizure but not currently on medication.

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Hearing concerns? *

Yes

Vision Concerns? *

Yes

Physical Restrictions?

Doctor's letter is required for some P.E. Adaptations

Uses mobility aide (wheelchair, walker, crutches, etc.)

其他:

Describe health history (operations, serious accidents, and serious illness)

Diseases/Conditions

Chicken Pox

Measles (Rubella)

Mumps

Rubella (3 day)

Scarlet Fever

Sinusitis

Eczema

Whooping Cough

Heart Disease

Rheumatic Fever

Kidney/Bladder Disorder

Congenital Condition

其他:

Note: If medication is needed, the parent must complete a medication authorization form before the first dose of medication can be given at school. This health concern information may be shared with school personnel as necessary to benefit the health and safety of this student and others. Please keep school staff informed as to any changes to the information provided so the student's records can be updated as needed. *

Please type your name to acknowledge the information provided is correct and you have read the above statement.

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