St. George School Medical History Student Name(Required) Your child’s learning depends upon good health. To gain the most from his/her education, it is important for the school nurse to have an updated health history. This information will be shared with staff as deemed necessary by the school nurse.Family Doctor(Required) Family Doctor PhoneHas your child had a physical exam in the past two years?(Required) Yes No Date of last physical exam MM slash DD slash YYYY Hospital Preference(Required) Does your child have insurance?(Required) HMO Private Medicaid/MC+ None Family Dentist Family Dentist PhoneHas your child had a dental exam in the past year?(Required) Yes No Orthodontist Orthodontist PhoneIs your child currently under an orthodontist's care?(Required) Yes No HEALTH CONCERNS: Does your child have any of the following health concerns? Allergies(Required) Yes No To drugs, food, insects, pollen? Please list: Asthma(Required) Yes No Triggered by: Treatment: Please provide dates of required urgent or ER care due to asthma in the past 3 years: Daily asthma medications at home: Daily asthma medications at school: Please provide the doctor's name and date asthma was diagnosed: ADD/ADHD(Required) Yes No Medications taken daily at home: Medications taken daily at school: Diabetes(Required) Yes No Takes Insulin Yes No Date diagnosed MM slash DD slash YYYY Epilepsy/Seizures(Required) Yes No Describe seizure:Seizure medications: Date of last seizure MM slash DD slash YYYY Heart Condition(Required) Yes No Physical restrictions Yes No Describe heart condition: Medications: Bone/Joint Problem(Required) Yes No Physical restrictions Yes No Describe bone/joint problem: Medications: Eye Glasses/Contacts(Required) Yes No Reason for eye glasses/contacts Reading Distance Crossed Lazy Eye Difficulty Seeing Ear Problems(Required) Yes No Describe Frequent Infections Tubes Difficulty Hearing Hearing Aid in Left Ear Hearing Aid in Right Ear Explain: Mental Health Concerns(Required) Yes No Describe Depression Bi-Polar Anxiety Medications: Other health information, concerns, or physical restrictions including injuries or surgeries:MEDICATION POLICY: Any medication at school must be sent to the nurse in the original container and/or pharmacy labeled bottle (pharmacy will label a second bottle for school) accompanied by a signed note from the parent listing medication, dose, time and dates to be given, and reason.
