2024-2025 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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Email *
Student's Last Name *
Student's First Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Grade in Fall of 2024 *
Name of Parent/Guardian Completing This Form *
Food Allergies (if none, write "none") *
Drug Allergies (if none, write "none") *
Other Allergies (if none, write "none") *
Does your child require an epi-pen and/or rescue inhaler? If yes, please explain and submit asthma and/or allergy action forms. *
Is there any current or past history of seizure disorder? *
Is there any current or past history of asthma? If current, please submit an asthma action form. *
ANY CURRENT MEDICAL CONDITIONS (I.E. CROHNS, DIABETES, HYPOTHYROID, CELIAC DISEASE, AUTOIMMUNE DISORDERS, GHD, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
ANY CURRENT OR PAST PSYCHOLOGICAL DISORDERS (I.E. ADHD, DEPRESSION, ANXIETY, EATING DISORDERS, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
DOES THE STUDENT WEAR GLASSES? *
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE". *
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): *
Required
NAME AND NUMBER OF PEDIATRICIAN *
NAME AND NUMBER OF DENTIST *
NAME AND NUMBER OF PSYCHOLOGIST/THERAPIST, IF SEEING ONE, IF NOT PLEASE ENTER "NONE" *
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