Denville Township Public Schools

DENVILLE TOWNSHIP PUBLIC SCHOOLS

HEALTH UPDATE 2017-2018 School Year

1. Student Name: ______Teacher: ______Grade:_____

2. Has your child had any serious accidents, injuries, illness, or surgery recently? If yes, please describe on the back of this form. Circle one: YES / NO

3. Is your child taking any medication at home? Circle one: YES / NO

If yes, please list: Medication: ______

and the reason for medication: ______

4. Does your child have any medical or physical conditions (ie: diabetes, seizure disorder, headaches, nosebleeds, physical limitations) Circle one: YES / NO

If yes, please describe on the back of this form.

5. Does your child have any allergies to medications, foods, insects, animals, pollens? Circle one: YES / NO Note: If yes please describe allergy and symptoms on the reverse side of this form.

My child is allergic to:______.

6. Does your child have asthma? Circle one: Yes / No

If an inhaler or nebulizer treatment will be needed in school you must provide the school nurse with an ASTHMA TREATMENT PLANcompleted and signed by your physician.The “Asthma Treatment Plan – Student” is atwo-sided formavailable in the nurse’s office, or you may find the form online at the Pediatric/Adult Asthma Coalition of New Jersey website:

Please note: the back of the form is to be completed and signed by the parent.

7. Does your child wear glasses? Yes / No (or) Contact lenses? Yes / No

If yes,is the correction for near or far vision?Circle one: Near-sighted / Far-sighted

Date of last professional eye exam:______.

Date of last prescription change: ______.

8. Additional information about your child’s health, behavior, family or home life you want the school to be aware of? ______

(please use other side of this form to write detailed information)

9. Recent immunizations?Physician documentation (from your child’s pediatrician’s office)of any updates to your child’s immunization record should be submitted to the school nurse.Please note: an important part of your child’s school health file is an accurate, up-to-date record of his or her immunizations.

As a parent/guardian of the above named student, I hereby authorize the release of pertinent medical information (i.e.: conditions, allergies, treatment regimes) to be exchanged among appropriate professional staff involved in the care of the above named student. This consent is intended to allow the staff to better serve my child’s needs.

Signature of Parent/Guardian:______

Date: ______