Niagara Wheatfield Central School District

Health History – Latex Allergy: ______School Year

PART A – STUDENT HEALTH HISTORY / MEDICATION AUTHORIZATION BY PARENT

Student Name:______DOB:______Grade/Teacher: ______

Mother ______(home)______(work)______(cell)______

Father ______(home)______(work)______(cell)______

Emergency: ______(home)______(work)______(cell)______Emergency: ______(home)______(work)______(cell)______

1. At what age was your child diagnosed with a latex allergy? ______

2. What symptoms led to the diagnosis? ______

3. Approximately how many allergic reactions has your child experienced? ______

4. When was his/her last allergic reaction? ______

5. Number of hospitalizations due to an allergic reaction? ______None _____

6. What type of reaction does your child typically experience? Please describe: ______

7. What treatment / medication is required to treat a reaction? ______

______

8. Has your child ever experienced an allergic reaction at school? _____ Yes ____ No

If yes, please describe: ______

9. Does your child have asthma? ____ Yes ___ No (Asthma can increase severity of reaction)

I request that my child receive the medication as prescribed by our licensed healthcare provider.

  • I understand that school staff/coaches can and will be informed of my child’s health concerns/diagnosis, on a need-to-know basis, in order to provide safe, appropriate care for the above-mentioned school year.
  • I understand that an Emergency Care Plan will be shared with appropriate staff/coaches (if applicable) in case emergency treatment is needed.
  • I understand that a parent, guardian or responsible adult must furnish the health office with the Prescription or Over-the-counter medication in the properly labeled ORIGINAL, UNOPENED/SEALED container.
  • I understand that medication will not be accepted if it is not provided in the original container.
  • I understand that the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication, including field trips.
  • I agree to have my child evaluated by my healthcare provider should the school determine my child is

requesting medication excessively.

  • My signature below constitutes permission for the health office staff to contact my healthcare provider regarding my child’s health care at school.

X Parent/Guardian Signature ______Date______

** PLEASE REQUEST A SECOND BOTTLE FROM THE PHARMACIST FOR PRESCRIPTION MEDICATION FOR USE AT SCHOOL

PRESCRIBER’S AUTHORIZATION FOR MEDICATION ADMINISTRATION

______School Year

B. LICENSED HEALTH CARE PROVIDER MUST COMPLETE FOR PRESCRIPTIONS AND / OR

OVER-THE-COUNTER MEDICATIONS:

Student Name: ______Date: ______

The following plan of care should be initiated for the above named student:

Student has the following allergy / allergies: ______

[1.] If exposure or suspected exposure to latex has occurred and / or the only symptoms are: ______

Give: ______

Medication Dosage Route Frequency/Time

Possible Side Effects: ______

[2.] If the following symptoms develop: ______

Give:______

Medication Dosage Route Frequency/Time

Possible Side Effects: ______

[3.] Other: ______

Medication Dosage Route Frequency/Time

Possible Side Effects: ______

Student allowed to carry and administer medication during sports / field trips: ____YES ____NO

  • Student has been instructed in and understands the purpose, appropriate method and frequency of use of prescribed medication(s).
  • Student understands that irresponsible behavior or misuse/abuse of the medication will result in the privilege of carrying the medication to be rescinded.

X SIGNATURE OF HEALTHCARE PROVIDER ______Date:______

Physician Stamp:

**** IMPORTANT FOR INHALERS AND EPI-PENS ONLY ****

Because of the severity of the health care problem, (severe asthmatic or severe allergic condition), this student should be allowed to carry and self-administer his/her own medication in school. I have determined that this student is self-directed and the student has demonstrated sufficient maturity to carry this drug safely.

Healthcare Provider Signature ______

A CHANGE IN ANY OF THE ABOVE INFORMATION REQUIRES A REVISED WRITTEN PHYSICIANS ORDER

5/09 This plan is in effect for the current school year and summer school as needed