Medical Information for Students

Instructions

This form is only to be completed by parents of currently enrolled students when there is a change in medical information, or for new students with medical issues. If there no changes from the previous school year, you do not need to complete this form.
Parents may also complete this form at any time during the year when there are medical information changes.
Responding "yes" to any of the questions below will open up new questions.
if you have difficulty with this form, send a note to our webmaster. If you have a medical question, please contact district nurse Rachel Piersol via emailor phone: 734-424-4100 ext. 1051.

Parent's Full Namerequired

Parent's Full Name

Student's Full Namerequired

Student's Full Name

Parent's Emailrequired

Parent's Email

Best Daytime Phonerequired

Best Daytime Phone

Ext

Food Allergies

Food Allergies*

Does this student have any food allergies?

Yes No

List Food Allergiesrequired

Please list any food allergies.

Degree of Allergy*

Are any of these food allergies life-threatening?

Yes No

Daily Medicationsrequired

Please list any daily medications needed (write n/a if none).

Rescue Medicationsrequired

Please list any rescue medications needed (write n/a if none).

Medication Allergies

Medication Allergies*

Does this student have any medication allergies?

Yes No

List Medication Allergiesrequired

Please list any medication allergies.

Degree of Allergy*

Are any of these medication allergies life-threatening?

Yes No

Bee/Insect Allergies

Bee/Insect Allergies*

Is this student allergic to bee or insect stings and bites?

Yes No

List Bee or Insect Allergiesrequired

Please list any bee or insect allergies.

Degree of Allergy*

Are any of these allergies life-threatening?

Yes No

Medicationsrequired

Please list any medications needed/used in the event of an insect sting or bite.

Other Allergies

Other Allergies*

Does this student have any other serious allergies not noted above?

Yes No

List Other Allergiesrequired

Please list any other serious allergies.

Daily Medicationsrequired

Please list any daily medications (write n/a if none).

Rescue Medicationsrequired

Please list any rescue medications used/needed (write n/a if none).

Asthma

Asthma*

Does this student have asthma?

Yes No

List Asthma Triggersrequired

Please list this student's asthma triggers.

Physical Restrictionsrequired

Please list any physical education restrictions due to asthma (write n/a if none.)

Daily Medications/Treatmentsrequired

Please list any daily prescribed treatments to be used in school (write n/a if none).

Rescue Treatmentsrequired

Please list any rescue treatments or medications (write n/a if none).

Hospitalizationsrequired

Date of last hospitalization related to asthma (write n/a if none).

Treating Physicianrequired

Name and phone number of treating physician.

Diabetes

Diabetes*

Does this student have diabetes?

Yes No

Prescribed Treatmentsrequired

Please list any currently prescribed treatments to be used in school.

Other Oral Medicationsrequired

Please list all oral medications (for any condition) that this student is taking.

List special scheduling needs or physical restrictions.required

Please list any special scheduling of lunch and/or physical activities (write n/a if none).

Treating Physicianrequired

Name and phone number of treating physician.

Seizure Disorder

Seizure Disorder*

Does this student have a seizure disorder?

Yes No

Describe seizure disorder.required

Type of seizure disorder.

Physical Restrictionsrequired

List any physical education restrictions due to this condition (write n/a if none).

Daily Medicationsrequired

Please list any daily medications needed in school (write n/a if none).

Rescue Medicationsrequired

Please list any rescue medications (write n/a if none).

Treating Physicianrequired

Name and phone number of treating physician.

Other Health Conditions

Chicken Pox*

Has this student had the chicken pox?

Yes No

Date of Chicken Poxrequired

Please list the approximate date the student had chicken pox.

Heart Condition*

Does this student have a heart condition?

Yes No

Heart Conditionsrequired

Please describe any heart conditions.

Other Medical Conditions*

Does this student have any other life-threatening conditions not noted above?

Yes No

Describe Medical Conditionsrequired

Please describe any other life-threatening medical conditions not noted above.

Prescription Medications*

Is this student currently taking any prescription medications?

Yes No

Medicationsrequired

For each prescription medication your child currently takes, please list the medication name, when taken, and what it is taken for.

Dietary Restrictions*

Does this student have any dietary restrictions?

Yes No

Restrictionsrequired

Please list any dietary restrictions.

Acknowledgements

Permission to Share Medical Information:

I agree that the school nurse may share health information with appropriate school personnel to aid present and future educational decisions, and, if needed, make and distribute an emergency plan based on this information.

(For example: classroom teacher, para educator, lunchroom personnel, bus driver, or other staff as appropriate.)

Grant Permission to Share Info*

Yes No

Permission for Emergency Treatment

I give permission for release of information on this form for confidential use in meeting this student's health and educational needs in school. I understand that any changes regarding this student's health history need to be communicated to the school nurse/principal. I hereby authorize officials of the district to contact directly the person(s) named within this registration information and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency for the health of the student. In the event that the parents/guardians or contact persons named in this registration cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the student. I will not hold the school district financially responsible for the emergency care and/or transportation of said student.

(This applies only to medically necessary treatment in the absence of a parent or guardian decision.)

Grant Permission to Treat*

Yes No