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BMS Medical Information
Please complete the following information for use by the school nurse. It is important that you please keep her advised of any new illnesses or injuries so that we may serve your child's need appropriately.
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* Indicates required question
Student's full name
*
Your answer
Student's grade
*
5th
6th
7th
8th
Check any of the following that apply to your student
Heart Disease or Condition
Kidney Disease
Rheumatic Fever
Convulsions
Diabetes
Asthma
Allergies
Tuberculosis
Chicken Pox
Mumps
Measles
Other:
Please give date and details for any illness or injury checked above
Your answer
Major Illnesses (Please be specific)
Your answer
Significant Injuries (Please be specific)
Your answer
Daily Medication
If your child is presently taking medication for an extended time and will be taking it during school hours, please list below:
Name of Medication(s) and time and schedule of administration
Your answer
Optional: Medications your child takes during non-school hours
Your answer
Please type your full name (parent or legal guardian) below to acknowledge you have read and completed this form.
*
Your answer
Date
*
MM
/
DD
/
YYYY
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