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Dear parent/ guardian,

Student Name: ________________________________________
Grade: _____________

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
Food Allergies: 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 Examination between 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.

Source: http://www.qcsd.org/cms/lib04/PA01000005/centricity/domain/70/11-12_HS_and_FC_Medication_Consent_and_Health_History_Update.pdf

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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

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