Parent/Legal Guardian ______HR Teacher ______Grade______
Best phone numbers to reach you in an emergency: #1 ______Cell Home Work #2 ______Cell Home Work
Email: ______Text # ______
Preferred method for school nurse to contact you: 5 Phone 5 Text 5 E-mail Insurance: 5 Medicaid/Health Choice 5 Private 5 None
Is this your child’s 1st time attending a public school in North Carolina? 5 Yes 5 No
Does your child have an acute or chronic health condition? 5 No [If no, stop here & sign below.] 5 Yes [If yes, proceed to next section.]
Health Conditions – New or Existing – Please check all that apply.
5 ADHD 5 Anxiety 5 Autism Spectrum Disorder 5 Bi-Polar 5 Depression 5 Other Treatment ______
5 Allergies List ______Treatment: 5 Epinephrine Injection 5 Benadryl
5 Asthma Treatment: 5 Rescue Inhaler 5 Nebulizer 5 Other ______Last asthma attack ____/____/______
5 Concussion/Head Injury Date ____/____/______Loss of Consciousness 5 Yes 5 No Complications______
5 Diabetes Type I _____ Type II _____ Treatment: 5 Insulin pump 5 Insulin prefilled pen 5 Insulin vial and syringe 5 Oral medication
5 Diet order / Meal modifications needed Type:______5 Swallowing problems 5 Feeding tube/G button
5 Epilepsy/Seizures Treatment: 5 Diastat® 5 Midazolam 5 Other ______Last seizure ____/_____/______
5 Eyes/Vision Wears glasses/contacts ______Vision loss: right eye ______left eye ______5 Dental Problems
5 Gastro-intestinal Condition IBS/Crohn’s _____Other ______Treatment______Colostomy 5Y 5N
Ileostomy 5Y 5N
5 Hearing loss right ear ______left ear ______Hearing aid(s) 5 Yes 5 No Speech Problems 5 Yes 5 No
5 Heart Condition List______Treatment______
5 Migraine Headaches Treatment ______
5 Orthopedic/Muscular Condition List______Assistive/adaptive device needed 5 Yes 5 No
5 Sickle Cell Disease 5 Sickle Cell Trait 5 Hemophilia 5 Leukemia 5 Other______
5 Skin Condition 5 Eczema 5 Other – list______Treatment______
5 Urinary / Kidney Problems List ______Catheterization needed 5 Yes 5 No
5 Other Health Condition – Describe______Treatment______
Medications needed at school* – Please check all that apply. *See School Nurse for Forms.
Emergency: 5 Insulin 5 Glucagon 5 Inhaler 5 Nebulizer 5 Diastat® 5 Midazolam 5 Epinephrine 5 Antihistamine/Benadryl 5 Other
Daily – list: ______PRN – list ______
This information will be kept confidential and shared only to ensure student’s health, safety, and well-being at school.
It is the responsibility of the parent/guardian to notify the school about health conditions and secure emergency and/or individualized health plans
and provide the medication, written healthcare provider orders, and equipment/supplies needed at school.
Parent/Guardian Signature______Date______
File positive health conditions in confidential Individual Health Record.
Date reviewed by school nurse______Initials______EAP, IHP, Special Procedure/Med. Form sent______Rev/ 842016