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Online Health Update
Annual update about health conditions and medications and permission for OTC medications in school
Last Name *
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First Name *
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Date of Birth (optional)
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Grade *
Name of parent completing form and email address *
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FOOD ALLERGIES (IF NONE, ENTER "NONE") *
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DRUG ALLERGIES (IF NONE, ENTER "NONE") *
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OTHER ALLERGIES (IF NONE, ENTER "NONE") *
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DOES YOUR CHILD REQUIRE AN EPI-PEN AND/OR RESCUE INHALER? IF YES, PLEASE EXPLAIN AND SUBMIT ASTHMA and/or ALLERGY ACTION FORMS (DOWNLOAD FROM SCHOOL WEBSITE). *
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ANY CURRENT OR PAST HISTORY OF SEIZURE DISORDER? IF YES, PLEASE SUBMIT SEIZURE ACTION PLAN (DOWNLOAD FROM SCHOOL WEBSITE). *
ANY CURRENT OR PAST HISTORY OF ASTHMA? IF CURRENT, SUBMIT HARD COPY ASTHMA ACTION FORM (DOWNLOAD FROM SCHOOL WEBSITE). *
ANY CURRENT MEDICAL CONDITIONS (I.E. CROHNS, DIABETES, HYPOTHYROID, CELIAC DISEASE, AUTOIMMUNUE DISORDERS, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
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ANY CURRENT OR PAST PSYCHOLOGICAL DISORDERS (I.E. ADHD, DEPRESSION, ANXIETY, EATING DISORDERS, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
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HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
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DOES THE STUDENT WEAR GLASSES? *
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE". *
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THE FOLLOWING NON-PRESCRIPTION (aka OTC) MEDICATIONS MAY BE ADMINISTERED BY AN ADULT (NOT NECESSARILY A NURSE) IN SCHOOL, AS NEEDED, BASED ON DOSAGE, AGE, WEIGHT GUIDELINES (check as many as applicable): *
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NAME AND NUMBER OF PEDIATRICIAN *
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NAME OF NUMBER OF DENTIST *
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NAME AND NUMBER OF PSYCHOLOGIST/THERAPIST, IF SEEING ONE, IF NOT PLEASE ENTER "NONE" *
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