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FCAHS Medical Request
Teachers, Please complete this form before sending students to the nurses office
* Indicates required question
Email
*
Record my email address with my response
1.) Teachers Name and Extension
*
Your answer
2.) Students First and Last Name
*
Your answer
3.) Student Symptoms
*
Fever
Headache
Stomach Ache
Nosebleed
Pain
Soar Throat
Shortness of breath/Difficulty breathing
Cough/Cold symptoms
Dental pain/Injury
Earache
Insect bite/ Sting
Rash
Nausea/Vomiting
Other:
Required
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