TROY BAND Student Medical and Treatment Authorization Form
Student’s Name_____________________________________________Age________________ (first) (last) (m.i.) Birthdate__________________________________Male________Female__________________ Home Address__________________________________________________________________ City_____________________________________________State__________Zip Code________ Home Phone Number____________________________________________________________ Mother/Guardian________________________________________________________________
Work Phone_____________________________________
Cell Phone______________________________________
Pager Number___________________________________
Father/Guardian________________________________________________________________
Work Phone_____________________________________
Cell Phone______________________________________
Page Number____________________________________
Name of Emergency Contact OTHER THAN PARTENT:______________________________
Relationship to student_____________________________
Phone Number____________________________________
Name of Secondary Emergency Contact OTHER THAN PARENT:______________________
Relationship to student_____________________________
Phone Number____________________________________
Family Doctor____________________________ Office Phone__________________________ Family Dentist____________________________ Office Phone__________________________ Orthodontist______________________________ Office Phone__________________________ Health Insurance Carrier________________________________________________________ Policy/ID #_______________________________ Policy/Plan#___________________________ Policy Holder’s Name____________________________________________________________ Health Insurance Phone #_________________________________________________________
Do any pre-certification, notification, or other requirements exist with respect to the health insurance of the student? If so specify:______________________________________________ ______________________________________________________________________________ Current Medications: __________________________________________________________ ______________________________________________________________________________ General: Does student have: ( if “yes” explain) ___Yes ___No Allergies (i.e. food, drug)?___________________________________________ ___Yes ___No Asthma?_________________________________________________________ ___Yes ___No Heart Condition?___________________________________________________ ___Yes ___No Diabetic?_________________________________________________________ ___Yes ___No Vision Impairment?_________________________________________________ ___Yes ___No Hearing Impairment?________________________________________________ ___Yes ___No Other?____________________________________________________________ Is student subject to: (if “yes” explain) ___Yes ___No Headaches(especially migraines)?_____________________________________ ___Yes ___No Seizures?________________________________________________________ ___Yes ___No Motion Sickness?__________________________________________________ ___Yes ___No Fainting? ________________________________________________________ ___Yes ___No Sleep Walking? ___________________________________________________ ___Yes ___No Upset Stomach?___________________________________________________ ___Yes ___No Other?___________________________________________________________ Does student have a reaction to: (if “yes” explain) ___Yes ___No Bee Stings? ______________________________________________________ ___Yes ___No Penicilin?________________________________________________________ ___Yes ___No Other Drugs?_____________________________________________________ ___Yes ___No Other?___________________________________________________________ ___Yes ___No Has the student had any serious illness or surgery within the past ten years?
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________
___Yes ___No Are any drugs ineffective in treatment?_________________________________ ___Yes ___No Does the student wear contact lenses?__________________________________ Date of last tetanus shot: ________________________________________________________ Routine Medications needed daily_________________________________________________ ______________________________________________________________________________
Student Name:________________________________________________________________ (First) (Last) (M.I) ___Yes ___No Can your student be given over the counter medications such as: Tylenol, Imodium AD, Tums, etc….for normal ache and pains?
(Parent/Guardian Signature) Date Relationship to student ____________________________________ Does your child have your permission to swim? ___Yes ___No
Referenz 1 ) Parkinson Study Group. Pramipexole vs levodopa as initial treatment for Parkinson disease: A randomized controlled trial. JAMA 2000: 284:1931-38. 2 ) Parkinson Study Group. Pramipexole vs Levodopa as Initial Treatment for Parkinson Disease. A 4-Year Randomized Controlled Trial Arch Neurol 2004: 61:1044-53. 3 ) Corbin A et al. Maintained pramipexole monotherapy treatment
Epilepsy & Behavior 7 (2005) 539–542Effects of levetiracetam on sleep in normal volunteersCarl W. Bazil a,*, Julianne Battista a, Robert C. Basner ba Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USAb Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USAReceived 13 June 2005; revised 1 Augu