JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Medical and Allergy Information 23-24
Marseilles Elementary School District #150
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student’s Legal First Name
*
Your answer
Students Legal Last Name
*
Your answer
What grade will they be going into in the 23-24 school year?
*
Choose
EC (3yrs)
Pre - K (4yrs)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Birthday:
*
MM
/
DD
/
YYYY
Home Phone:
Your answer
Cell Phone:
*
Your answer
Does your child have allergies?
*
Yes
No
If yes, what is your child allergic to:
Your answer
Is allergy medication needed at school?
*
Yes
No
N/A
Does your child have asthma?
*
Yes
No
If yes, triggers/symptoms?
Your answer
Is asthma medication needed at school?
*
Yes
No
N/A
Option 4
Does your child have diabetes?
*
Yes (If yes, please send care plan to the nurse)
No
Is diabetes medication needed at the school?
*
Yes
No
N/A
Does your child have Seizures?
*
Yes (If yes, please send care plan to the nurse)
No
Is seizure medication needed at school?
*
Yes
No
N/A
Does your child have heart problems?
*
Yes
No
If yes, please describe their heart problems.
Your answer
Is heart medication needed at school?
*
Yes
No
N/A
Does your child have ADD/ADHD?
*
Yes
No
Is ADD/ADHD medication needed at school?
*
Yes
No
N/A
Does your child have vision problems?
*
Yes
No
Does your child wear glasses or contacts?
*
Yes
No
N/A
Has your child ever had an eye exam? If yes, when?
*
Your answer
Does your child have hearing problems?
*
Yes
No
If yes, please describe their hearing problems?
Your answer
Does your child wear hearing aid(s)?
*
Yes
No
N/A
Does your child have orthopedic issues?
*
Yes
No
If yes, please describe their orthopedic issues?
Your answer
Does your child have any orthopedic restrictions?
Your answer
Is your child taking any medications regularly?
*
Yes
No
1. If
yes
, please list medication below. (You will need to include the name of the
medication, dosage, condition for the medication, and if they take at home or school
) Please list one medication per box.
Your answer
2. If
yes
, please list medication below. (You will need to include the name of the
medication, dosage, condition for the medication, and if they take at home or school
) Please list one medication per box.
Your answer
3. If
yes
, please list medication below. (You will need to include the name of the
medication, dosage, condition for the medication, and if they take at home or school
) Please list one medication per box.
Your answer
Does your child have a diagnosis of an allergy from a healthcare provider?
If you answered
NO
, please scroll down the bottom of this form and complete the last two questions.
*
Yes
No
What is your child allergic to?
Peanuts
Tree Nuts(Walnuts, Pecans, Etc.)
Eggs
Milk
Latex
Soy
Insect Strings
Fish/Shellfish
Chemicals
Vapors
Other
What was the age of student when allergy first discovered?
Your answer
How many times has the student had a reaction?
Never
Once
More than once
Clear selection
Explain their past reaction:
Your answer
What are their symptoms?
Your answer
Are the food allergy reactions:
Same
Better
Worse
Clear selection
What are the early signs of symptoms of your student's allergic reaction? (Please be specific)
Your answer
How does your student communicate his/her symptoms?
Your answer
How quickly do symptoms appear after exposure to food(s)?
Your answer
Please select the symptoms that your student has experienced in the past with this allergen on their skin:
Hives
Itching
Rash
Flushing
Swelling (face, arms, hands, or legs)
Please select the symptoms that your student has experienced in the past with this allergen on their mouth:
Itching
Swelling (lips, tongue, mouth)
Please select the symptoms that your student has experienced in the past with this allergen with their abdominal:
Nausea
Cramps
Vomiting
Diarrhea
Please select the symptoms that your student has experienced in the past with this allergen with their throat:
Itching
Tightness
Hoarseness
Cough
Please select the symptoms that your student has experienced in the past with this allergen in their lungs:
Shortness of breath
Repetitive Cough
Wheezing
Please select the symptoms that your student has experienced in the past with this allergen with their heart:
Weak pulse
Loss of consciousness
Does your student have an Epi-Pen
Yes
No
Clear selection
Will your student carry their Epi-Pen on their person
Yes
No
Clear selection
Will the Epi-Pen be kept in the heath office?
Yes
No
Clear selection
Does your student know what food to avoid?
Yes
No
Clear selection
Does your student ask about food ingredients?
Yes
No
Clear selection
Does your student read and understand food labels?
Yes
No
Clear selection
Does your student tell and adult immediately after an exposure?
Yes
No
Clear selection
Does your student wear a medical alert bracelet, necklace, or watchband?
Yes
No
Clear selection
Does your student tell peers and adults about the allergy?
Yes
No
Clear selection
Does your student firmly refuse a problem food?
Yes
No
Clear selection
Does your student know how to use their emergency medication?
Yes
No
Clear selection
Has the student ever administered their own emergency medication?
Yes
No
Clear selection
Please enter your first and last name as the person completing the Medical and Allergy form. Entering your name acknowledges that you have answered the above questions accurately and to the best of your knowledge and acts as your digital signature.
*
Your answer
Today:
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Marseilles Elementary School.
Report Abuse
Forms
