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Microsoft word - revised interval health history for pvrs

PIONEER VALLEY REGIONAL SCHOOL DISTRICT
NORTHFIELD, BERNARDSTON, LEYDEN, WARWICK
SCHOOL HEALTH SERVICES
INTERVAL HEALTH HISTORY
2010-2011
NAME: _______________________________________________ GRADE: _______ Dear Parent/Guardian: In order to keep your child’s health record up to date and to provide better health services to your child, we ask that you complete the following questions and return it to your school nurse. Please circle yes or no. Use the reverse side for detailed information if needed. 1. Do you give permission for the school nurse to administer the following medication(s) to your child? YES NO acetominophen (tylenol)
YES NO ibuprofen (motrin, advil)
YES NO diphenhydramine (benadryl)

2. Do you give permission for the school nurse to share pertinent medical information about your child
with other staff members on a need to know basis? YES NO
Bus drivers? YES NO
3. Do you give permission for the school nurse to contact your child’s physician for confirmation of physical examination and/or immunization status only? YES NO
4. What medication, if any, does your child take? 5. Does your child have any physical limitations that may require program modification or restrictions? 6. Please add any other problems or comments you like to bring to the attention of the school nurse or 7. Any significant accidents, illnesses, and or losses (death in family, a move, divorce, etc.) over the
DATE: ___________ SIGNATURE: _________________________________________

HEALTH INFORMATION Student : _________________ ___________________________________________________________________________________ Physician Name Health Insurance (please check one) □ Private (such as Blue Cross, Health New England) □ Public (such as MassHealth, Children’s Medical Security Plan) □ None ** ** If you do not have health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health care (Restrictions may apply). Please contact the school nurse for more information about these programs. All communications will be confidential. Please check all that applies to your child. __ Heart Condition __ Diabetes __ Asthma __ Seizure Disorder __ADHD __ ADD __ Other (Specify) ___________________________________ __ Al ergies (food, insects, medication, environment) (Specify) __________________________ __ Hearing problems (specify) __ Left ear __ Right ear __ Wears Eyeglasses __Contact Lenses __ Preferential Seating If emergency treatment is required, and the parents or legal guardians cannot be reached immediately,
my signature in the space provided below empowers the school authorities to exercise their own
judgment in calling the physician indicated above or to transport the child to a hospital emergency room.
Signature _______________________________________________________ Date _______________
*************************************************************************************************************************************************
Informed Consent for Potassium Iodide

___ I do not consent to have the school nurse or his/her designee administer Potassium Iodide to my child.
___ I consent to have the school nurse or his/her designee administer Potassium Iodide to my child.
Child’s
Address _____________________________________ _____________________________________ Telephone If consent is given, can your child swallow pills? Yes

Source: http://www.pioneervalley.k12.ma.us/Documents/Interval%20health%20history%20for%20PVRS.pdf

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