1. Within the past year has your child experienced a
5. Does your child take medication at home or in school on
serious illness or injury? (Circle answer) Yes No
a daily or as-needed basis? (Include inhaler if used).
(Circle answer) Yes No
If yes, list medication, dose, and times given:
2. Within the past year has your child required any
ongoing treatment or surgery (Circle answer) Yes No
Has your child had a SERIOUS ALLERGIC reaction
(requiring HOSPITALIZATION or EMERGENCY ROOM CARE) to any of the following? (CIRCLE all that apply)
3. Does your child have any of the following? Circle all FoodAllergies: List symptoms and history of treatment. that apply:
Insect Stings: List symptoms and history of treatment.
Seasonal/Environmental allergies: ______________
List on the reverse side of this form any additional health
Did a doctor prescribe an EpiPen?Yes No
concerns or conditions that you wish to share.
(If yes, provide an EpiPen for in-school use)
4. Does your child require any restrictions - especially in
7. I understand that the information provided on this form is
physical education (PE)?(Circle answer) Yes No
confidential. I agree to allow the nurse to share this
information with others who have a need to know to
(Circle answer) Yes No
The school doctor has written standing orders for the following medications to be given by the school nurse, when needed: CIRCLE EACH medication which may be given to your child. (Generic equivalent products may be provided). CIRCLE EACH topical product below which may be applied to your child: ( ) Check here if you DO NOT wish to have any of the above medications administered to your child. ( ) My child is allergic to the following medication (s): __________________________________________________________
Please update the nurse with a written physician’s copy of immunizations as they are received during the year. School Law requires students to provide proof of having had one Physical Examinationbetween September 1 of their sophomore year and June 1 of their junior year. Please initial your preference below: ( ) I would like my child to receive this examination in school, at no charge to me. ( ) I will have my child examined by my Family Physician. (Forms are available on-line at Parent Signature ______________________________ Print Name________________________ Date ________________ I give permission for the school nurse to give my child the medications indicated above.
WELCOME TO OUR PRACTICE Patient Information Sex: Male Female Marital Status: Married Single Divorced Separated Responsible Party (if someone other than patient) Spouse and/or Parent Information Responsible Party is also a Policy Holder for Patient Primary Insurance Information Responsible Party (if someone other than patient) Spouse and/or Parent Information Responsible Party
Managing stress and improving the quality of our lives leads to happiness and contentment, surely the most basic goal we all strive for. Read below for 10 tips on helping to achieve this healthful balance . A good nights sleep brings many benefits, including overall improvements in well-being, reduced risk of cardiovascular disease, depression and immune related disorders, help with weight regu