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Ras health form
STUDENT HEALTH RECORD
Student Name ______________________________________________________
PARENT SUPPLIED MEDICAL HISTORY AND EMERGENCY CONSENT FORM
Tuberculosis Screening is required for Admissions and must be updated every two years: Please indicate at least one
Mantoux or Tine Skin Test within past 2 years: Type ___________
Chest X-Ray (if previous positive reaction) within past 1 year:
Does your child have any present il nesses ________ Yes ________ No
Past history of:
Does your child suffer from any al ergies? _________Yes _________No
Does your child have a history of asthma? ________Yes _______No Does he/she carry an asthma inhaler? ________Yes _________No
Doers your child wear glasses or contact lenses _________Yes _________Noo
Does your child have trouble hearing or use a hearing aid? _________Yes _________No
Is your child on daily medication? _________Yes _________No
Please list the name of the medications and the time/frequency required: ____________________________________________________
Is there any health condition that the school should be aware or any limitations on your child’s physical activity?
Students may not receive medication unless written permission is signed by a parent or guardian. Parents of elementary students
wil be contacted before any medication is given by signing below:
1. I attest that al the above information is accurate.
2. I hereby give permission to the school to administer the fol owing medications to my child if deemed necessary by the
school nurse: Tylenol
(Please cross out (x) any medication NOT to be given to your child)
3. I hereby give permission for emergency measures to be initiated in case of accident or sudden il ness with the
Parent Signature __________________________________________________ Date _________________________________________
All students, as a condition for admission, must be current on their childhood immunization schedule. At a minimum this shal include Polio,
Diptheria, Pertussis, Tetanus, Measles, Mumps, Rubel a and Hepatitis B. This requirement can be waived only for health reasons or religious
convictions, documented by a letter from the student’s physician describing the student’s health exemption or with a sworn affidavit from the
parents attesting to their religious beliefs.
(To be completed by Licensed Physician, Nurse Practitioner or Physician’s Assistant)
Examination completed by: _________________________________________________________________________________________ Printed Name Ttile
Effects that Prescriptions Drugs have on the Voice Brand Name Manufacturer Drug Group Effect on Voice No effects on voice or speech mechanisms have been reported. Excessive coughing has been associated with the use of ACE inhibitors, which in turn, may lead to hoarseness and possible vocal tissue damage. Narcotics may produce an uninhibited or diminished drive to speak. Symptom
Committee for Human Medicinal Products (CHMP) CHMP Pharmacokinetics Working Party (PKWP) Questions & Answers: Positions on specific questions addressed to the Pharmacokinetics Working Party Background In the context of assessment procedures, the Pharmacokinetics Working Party (PKWP), or its predecessor the Therapeutic Subgroup on Pharmacokinetics of the Efficacy Working Party (EWP-PK sub