SCHOOL HEMOPHILIA RECORD
And
Emergency Action Plan
Please Complete both sides of the emergency medical plan for Hemophilia and add any further instructions you wish for your child.
Return to School Nurse as soon as possible.
NAME OF STUDENT ________________________________________
1. Does your child wear a “medic alert” bracelet? ___________________________________
2. What type of hemophilia does your child have? ___________________________________
3. How often does he/she have bleeding episodes_____________________________________
4. What body parts are most commonly affected by bleeding episodes? ___________________
__________________________________________________________________________
5. Describe symptoms when a bleeding episode occurs ________________________________
__________________________________________________________________________
6. List activities in which your child should NOT fully participate _______________________
__________________________________________________________________________
7. Name of medication taken routinely for pain relief or bleeding management______________
__________________________________________________________________________
8. In the event of a bleed, what steps should school personnel take? ______________________
__________________________________________________________________________
__________________________________________________________________________
PLEASE NOTE: If medication is taken at school, a medication authorization form must be completed and signed by the physician and parent and kept at school. This form may be obtained from the school nurse and is good for the school year in which it is written.
PLEASE READ THE EMERGENCY MEDICAL PLAN ON THE REVERSE SIDE AND ADD ANY FURTHER INSTRUCTIONS THAT YOU WISH FOR YOUR CHILD
Over
STUDENT NAME____________ TEACHER__________________________ GRADE_______
BUS#_________ PRIMETIME ____am ____pm CAR RIDER ____ am _____ pm
PARENT/GUARDIAN_______________________________ HOME PHONE ____________________ WORK PHONE_____________________
CELL PHONE _____________________
PRIMARY PHYSICIAN______________________________ PHONE ___________________________
SPECIALIST FOR HEMOPHILIA _____________________ PHONE ____________________________
HOSPITAL_________________________________________
_________________________________________________________________________________________________
HEMOPHILIA is a hereditary disease characterized by bleeding episodes that are either spontaneously or traumatically induced. Each type of hemophilia is caused by a deficiency in specific clotting factors. Bleeding problems are related to the amount of clotting factor present in blood.
SYMPTOMS: tingling or other sensation, limb held in abnormal position, discomfort or pain, area warm to touch, swelling, firmness and tenderness at site of bleed, restriction of range of motion.
· joints and muscles are most common bleeding sites.
· any bleeding in the head and neck area is a medical emergency (except nosebleeds).
INTERVENTIONS:
1. Note location of bleed and treat bleeding episodes promptly.
2. Administer any ordered medication.
List emergency medication your child uses for a bleeding episode______________________________
_____________________________________________________________________________________
3. Control the bleed by applying pressure to the site for 10-15 minutes.
4. Notify parent of bleed.
5. Allow child to rest while waiting for parent.
6. Resume activity slowly after bleeding episode.
7. DO NOT GIVE ASPIRIN or medicine containing aspirin for pain relief.
8. If bleeding is uncontrolled, or in head and neck region (except nosebleeds), contact parents regarding
emergency care. Call 911 and transport to hospital as necessary.
9. Additional instructions___________________________________________________________________ ________________________________________________________________________________________
________________________________________________________________________________________
I authorize the release and exchange of medical and educational information between my child’s physician and school staff
necessary in carrying out this service to my child.
PARENT/GUARDIAN SIGNATURE________________________________________ DATE_________
SCHOOL NURSE________________________________________________________ DATE__________