Student Medical Information Form
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Email *
Student Last Name *
Date of Birth *
Student First Name *
Grade *
MEDICAL HISTORY
The primary goal for obtaining a medical history is to understand the state of health of the student further. It assists in determining if anything within the history is related to any acute complaints for the purpose of care.
Please specify the student's current medical conditions or history of medical conditions: *
Does the student have any hearing or vision problems? (glasses, contacts, hearing aids, etc.) If yes please explain: *
List any allergies (medication, food, environmental. etc.). If no allergies type "none". *
Does the student have a prescribed: *
Required
DAILY MEDICATIONS 

All medications require the following to be provided to the health office before administration to the student can occur;

Prescription Medication
  • Written Doctor's orders provided to the Health office
  • Written permission from the parent / guardian authorizing the health office to administer the medication
  • Medication must be provided to the health office in its original container with pharmacy label
Over the Counter Medication
  • Written permission from the parent / guardian authorizing the health office to administer the medication
  • Medication must be provided to the health office in is original container
Self-Carry
  • A student may only self-carry their epi-pen or inhaler, provided that a doctor's order is on hand in the health office. They also have the option to leave it in the Health Office. 
Please list all medications your child takes:
MVSD has a formulary list of over the counter treatments and medications that are available in the Health Office. Specifically, if you would like Acetaminophen, Ibuprofen, Antacid, and in the case of a severe allergic reaction, Diphenhydramine administered to your student during the school day please notate below.

Per MVHS school policy students are not permitted to carry medications of any kind on their persons, with the exception of epi-pens and inhalers, as long as the epi-pen and inhaler meet the self-carry requirements.
Please check each box that applies. *
Required
CONSENT FOR MEDICATION ADMINISTRATION AND CONTINUED CARE


By answering YES below, I acknowledge that I am the parent / guardian, and:

I hereby request and give my permission for a designated member of the school staff to administer medication to my student. I will not hold liable the Merrimack Valley School District, school nurse(s), principal or members of the school staff that assist my student with their prescription or over the counter medication.

I give permission for the Health Office to provide nursing care as defined in the NH Nursing Scope of Practice. In case of serious illness or injury, the school may make whatever arrangements deemed necessary for the care and well-being of my student and contact me as soon as possible.

I give my permission to the school nurse(s) to share health information necessary to benefit my student's health or education with school staff and give my permission to the school nurse(s) to speak with emergency personnel staff as necessary.

*
Required
Name of Parent / Guardian filling out this form. *
Date *
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This form was created inside of Merrimack Valley School District.