Pitt County Schools

2016-2017 STUDENT HEALTH INFORMATION

Grades Pre-K thru 12

An Important Message from Your Child’s School Nurse:

In order for the school nurse to have the most current health information on your student and to help your student have a healthy and successful year, please complete, and return this form to the teacher or school nurse by September 2, 2016. If you have any questions completing this form or need to talk with your school nurse, please do not hesitate to contact the school office and ask to speak with the school nurse.Thank you for your cooperation!

CHILD’S HEALTH INFORMATION (to be completed by parent/guardian):

Child’s First Name / Child’s Last Name / Date of Birth (month/day/year) / M/F / School / Homeroom
Teacher / Grade
Parent/Guardian’s First and Last Name / Telephone Numbers
(daytime numbers) / Street Address / City / Zip
Home –
Work –
Cell -
E-Mail Address
/ Bus or Car Rider / Bus Number (if bus rider)
Physician’s Name / Telephone #
/ Dentist’s Name / Telephone # / Specialist’s Name / Telephone #

INSURANCE INFORMATION:

Does your child have Medicaid? Yes No Health Choice? Yes No
Private Insurance? Yes No Uninsured? Yes No

PERMISSION STATEMENT:

I give my permission for the school nurse to share or receive health-related information needed to care for my above-named child with other healthcare providers (for example doctors, specialists, case managers) during the 2016-2017 school year. The purpose of exchanging this data shall be for diagnostic/educational purposes only. I understand that I may revoke this consent at any time, except to the extent that action based on this consent has been taken. This authorization is fully understood and is made voluntarily on my part.
Signature of Parent / Legal Guardian / Date

**It is the responsibility of the parent/guardian to notify the school nurse of any changes

in the student’s health status during the school year.

Does your child have a chronic/ongoing health condition?
___ *Yes *IF YES, PLEASE CAREFULLY READ AND COMPLETE THE BACK OF THIS FORM __ No

Check any of the conditions below that a physician has diagnosed your child as having:

____ ADHD

____ ASTHMA

Does your child have asthma and need an inhaler at school: YES* NO

If YES, you MUST provide: Medication Authorization Form, Rescue Inhaler, Spacer and Asthma Action Plan

____ SEVERE ALLERGIES

Does yourchild have an EpiPen/Twin Jett/AuviQ (or other medication) for a life threatening allergy? YES* NO

If YES, you MUST provide: Medication Authorization Form and Emergency Medication.

If yes, what is your child allergic to? ______

List emergency medications: ______

____ CARDIAC (Heart) CONDITION

____ CANCER/ LEUKEMIA

____ DIABETES: (please circle) TYPE I or TYPE II

(Parent must provide Diabetes Care Plan from Physician for medication/procedures at school)

____ POTS (Postural Orthostatic Tachycardia Syndrome)

____ SEIZURE DISORDER/ Epilepsy

____ SICKLE CELL ANEMIA

____ HEAD INJURY/CONCUSSION (WITHIN THE LAST YEAR)

____ OTHER Please List: ______

Does your child:
Take prescription medication(s) at home daily? Yes No
Name of medication(s): ______
Take medication(s) at school? Yes* No
Name of medication(s): ______
*Medication Authorization Form required for medications taken at school, including over the counter medications taken for more than one week. These must be signed by the PARENT and PHYSICIAN.
Need a medical procedure performed at school? Yes* No
Type of procedure: ______
*Authorization for Specialized Health Care Procedure Form required for procedures performed at school.
Need special health related restrictions or accommodations at school? Yes* No
Explain: ______
*Doctor’s note required for special restrictions or accommodations.
Forms are available from your school nurse, your doctor’s office, or the Pitt County Schools website.

It is the responsibility of the parent/guardian to notify the school nurse of

any changes in the student’s health status during the school year.