Medical form 2011-12

MEDICAL INFORMATION
2011 - 2012
PLEASE PRINT. Form must be returned by July 1. Student may not attend class if form is not on file.
MEDICAL HISTORY
THE FOLLOWING INFORMATION MUST BE COMPLETED AND SIGNED BY THE STUDENT’S PARENT/GUARDIAN.
PHYSICIAN
HOSPITAL PREFERENCE (for non-emergencies only)
ORTHODONTIST

INSURANCE
Significant health condition and/or chronic illnesses (e.g., asthma, diabetes, seizures) *

Allergies (food, insects, medications, etc.)
Type
Prescription and non-prescription medications taken regularly or frequently at home (must be listed) *
Name
∗ IMPORTANT: Please contact the school nurse the week before the first day of school if your daughter has a significant health
condition and/or chronic illness listed above, or if she needs emergency medicine (e.g., Epi-Pen, Glucagon, asthma inhaler) at school. The nurse may be reached at 269-1238. Medications the school may administer (must check al that apply – no medications wil be given unless indicated on this form)

 Acetaminophen (Tylenol)
 Topical analgesic (Benadryl cream, gel)  Dental anesthetic gel (Orajel)  First aid antibiotic cream (Neosporin)  Benadryl (for allergic reactions)  Please cal parent/guardian before giving medications. MEDICAL EMERGENCY RELEASE
In the event that any il ness or injury occurs, and it is not possible to contact me, my designated contact persons, or my designated physician, I authorize the Academy of the Sacred Heart to obtain emergency medical, surgical, or dental treatment for my daughter.  SIGNATURE REQUIRED
Parent/Guardian’s name (Please print.) MEDICAL INFORMATION RELEASE
In order to best meet the education and developmental needs of your daughter, it is important that her faculty know about any medical
condition that she may experience and any medications prescribed for her.
 I authorize the school nurse to inform the administration, faculty, and staff of my daughter’s health condition and/or medicines
 I do not authorize the release of information about my daughter’s health.
Parent/Guardian’s signature
x
 SIGNATURE REQUIRED
Parent/Guardian’s name (Please print.) OVER …
MEDICAL EVALUATION AND IMMUNIZATION RECORD
THE FOLLOWING INFORMATION MUST BE COMPLETED AND SIGNED BY THE STUDENT’S PHYSICIAN OR
PHYSICIAN’S OFFICE. THIS INFORMATION WILL BE TREATED IN A CONFIDENTIAL MANNER.
PHYSICAL EXAMINATION
To be completed for students entering ASH-FIN, Little Hearts, PK, grades 1, 5, 9, and for all new students.
Date of last examination (must be within the last six months)
Postural
Other (Please mark with a  if satisfactory or an X if not satisfactory.)
Tuberculin Test
Date last given
This student may participate in the fol owing
Exceptions / special problems / dietary restrictions / recurring abnormalities /
prescribed medications / allergies
IMMUNIZATION RECORD
To be completed for students entering ASH-FIN, Little Hearts, PK, K, grades 1-9, and for all new students.
Month, day, and year dose was given
Date of next immunization
I certify that this child has received the above noted immunizations and is in compliance with rules set forth by the state of Louisiana, Department of Health and Hospitals, Office of Public Health. Physician’s signature x  SIGNATURE REQUIRED
Academy of the Sacred Heart  Medical Information  2011-2012

Source: http://www.ashrosary.org/images/docs/Medical%20Form%202011-12_final.pdf