Headache Migraine Update Form

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Please take a few moments to answer the following questions.

Your answers will be used to create an individualized school healthcare plan for your child.

Also, information will be shared on a need to know basis with school personnel for health, safety and educational purposes.

Student's Legal Name (last, first) *

Student Graduation Year *

Student's Date of Birth *

YYYY

Current Medical Diagnosis... *

List current medications your child takes- specify at home or at school... Reminder: Acetaminophen (Tylenol), ibuprofen (Advil) may be kept with the student in the container in which it was purchased. Students may not share medication with other students. Prescription medications must be kept in the health center in the pharmacy labeled bottle and a doctor's note must be on file. https://drive.google.com/file/d/1zyYdEz8nl9uADS1vcvvyQAYG87GAJMuk/view *

Does your child need any special health accommodations to be successful in the school setting? If yes, please state under the "other" option. *

Yes

Maybe

Other:

List doctor name and number who can verify above noted health information. *

Name of parent/person completing this form... *

Submit

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This form was created inside of East Peoria High School Dist 309.

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