HEALTH INFORMATION Summer, 2014
For office use:
Teacher/Grade:______
ID#:______
Student’s Name:______DOB:______Home Campus______
Please list any health problems or disabilities your child has that are not listed below.
What medical condition requires that your student be in special ed? ______
Please complete the following information regarding your child’s health need: (this info will be available to your child’s teacher and support staff).
Does your child use: / _____Wheelchair_____Walker
_____Crutches
_____Braces / For Allergies to food – please complete attached form.
In order for the cafeteria to make any substitutions, we
must have a doctor’s note which follows the TDA policy.
Does your child require: / _____Diaper Change
_____G-tube/button feeding
_____Catheterization / Does your child have allergies to medications, insects, or latex?
Yes ____ No ______Specify ______
Does your child have sickle cell anemia? Yes___ No___
Does your child have seizures? Yes___ No___ / Does your child have a trach? Yes___ No___
Type______
Last seizure:______/ Need suctioning? Yes___ No___
What happens when your child has a seizure?
______
______/ Is your child verbal____/nonverbal____
Does your child need assistance with restroom needs? Yes___ No___
On meds for seizure? Yes___ No___
Wears protective head gear? Yes ___ No ___
Does your child have problems with chewing or swallowing food? Yes___ No___
Is your child diabetic? Yes___ No___
Take meds for diabetes? Yes___ No___
Specify med:______
Blood Glucose monitoring? Yes___ No___
Frequency:______/ Does your child take meds at home? If so, please list:______
______
Does your child have asthma? Yes___ No___ / Will your child be taking meds during school hours? Yes___ No___ If so, please list:______
Take meds for asthma? Yes___ No___
Specify med:______/ ______
Does your child have ADD/ADHD? Yes___ No___ / Physician and Parent permission form will be required.
Take meds for ADD/ADHD? Yes___ No___
Specify med:______
Please share any information that would allow us to know more about your child’s physical/health needs
Does your child have a heart condition? Yes___ No___
Type of condition:______
***These are topical medications that are used in the school clinic for minor first aid: Calamine, zephiran for cleansing of cuts/scratches, petroleum jelly for chapped lips and normal saline for eyes.
Does your child have any physical restrictions?
Yes___ No___
Explain:______
Does your child wear hearing aids? Yes___ No___
Do you give approval for these medications to be used to treat your child while he/she is in school?
Yes___ No___
Does your child have a visual problem? Yes___ No___
Glasses? Yes___ No___