Microsoft word - health history form 2010 rev 3-2-2011.doc

ROCKBRIDGE COUNTY SCHOOLS
School Year 20_____ - 20_______
Student Health History Form
__________________________________________________________________________________________ Name: Last First Middle Initial __________________________________________________________________________________________ Street Address City Zip Code DOB: ______________ Grade: _______ Gender M F Home Room Teacher ________________________ Parent/Guardian: __________________________________phone: _____________ cell: __________________ EMERGENCY INFORMATION: (PLEASE LIST PEOPLE WHO CAN ASSIST IN CASE OF EMERGENCY
_____________________________________________________YES ____ NO____ YES ____ NO____ NAME RELATIONSHIP (H) PHONE CELL PHONE PICKUP IN EMERGENCY? Share info of _____________________________________________________YES ____ NO____ YES ____ NO____ NAME RELATIONSHIP (H) PHONE CELL PHONE PICKUP IN EMERGENCY? Share info of
Physician: ______________________________ office# _______________ Date of last visit? ______________
Dentist: ________________________________ office# _______________ Date of last visit? ______________
Does your child have the following health insurance (please check all that apply)
_____ Private _____ Medicaid ______FAMIS _____none
Have you applied for your child to receive Medicaid or FAMIS within the last 3 months? _____ Yes _____ No

Please check if your child has been treated for or is currently experiencing any of the following:
Allergies/Hay fever

*Please, check only if your child has required medication and/or treatment for asthma within the past 2 years –
checking this will require an action plan to be written and implemented
Please specify any allergies listed above, including medication and any other health conditions not listed above
that relate to your child:

PLEASE CONTINUE TO PAGE 2 ON THE BACK OF THIS FORM
Student Health History Form Page 2
Is your child currently under medical treatment? If so please explain:
______________________________________________________________________________________
Is your child taking medication (Prescription or over-the-counter) on a regular basis? ______ yes ______ no
If yes, please complete the following:
Medication: __________________________________________________ Dosage: __________________
Reason for use: ________________________________________________________________________

Medication: __________________________________________________ Dosage: __________________
Reason for use: ________________________________________________________________________
Rockbridge County Schools’ policy states that we can only administer over the counter medication brought in by
parent. Medication must be in its original sealed bottle. We will only administer Tylenol for complaints 2 times
a week without documentation from your child’s physician, because of the potential for side effects with
unsupervised, long- term use.
I give my permission for my child to have the following medication if a nurse or school personnel feel it is
necessary: Please send medication, we typically do not have these meds on hand for all students.
Tylenol
I want to be notified in writing if administered Yes No I want to be notified in writing if administered Yes No (Benadryl is used for emergencies only & you will be notified) It is necessary for your child’s safety that nursing staff share on a routine basis with the administration and personnel who work with your child the following conditions: bee sting allergy, other insect allergies, food allergy, asthma, seizures, diabetes. Are there any religious beliefs that would impact emergency care that you want communicated? Specify: Medical Authorizations (Please Read All)
CONSENT FOR TREATMENT
In the event that reasonable attempts to contact me have been unsuccessful; I HEREBY GIVE MY CONSENT for:
1) the administration of any treatment deemed necessary by the physician/dentist above or in the event the
designated preferred practitioner is not available, by another licensed practitioner; and 2) the transfer of my child
to the hospital above or to any hospital reasonably accessible. I accept full financial responsibility for the
payments of all charges made for medical services rendered. I absolve school officials of any liability who in good
faith complies with this request.
Parent/Guardian Signature: ______________________________________________ Date: ___ / ___ / ___
I DO acknowledge that it is necessary for the school nursing staff to notify school administrators of any medical
condition relating to: allergies, asthma, seizures, and diabetes.
Parent/Guardian Signature: ______________________________________________ Date: ___ / ___ / ___
I understand and accept that Rockbridge County Schools, its employees, agents or designees are not responsible
for any effect of the medication I have approved to be administered above.
Parent/Guardian Signature: ______________________________________________ Date: ___ / ___ / ___
Refusal of Consent (Note that in Life Threatening Situations Emergency Care
will be provided until a parent arrives on the scene)
REFUSAL OF CONSENT
I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring
immediate treatment, I wish the school authorities to take the following action:
I DO acknowledge that it is necessary for the school nursing staff to notify school administrators of any medical
condition relating to: allergies, asthma, seizures, and diabetes.
Parent/Guardian Signature: ______________________________________________ Date: ___ / ___ / ___
Thank you for completing this form

Source: http://www.rockbridge.k12.va.us/documents/health/student_health_history_form.pdf