Naaleh Online Health Update 2020-2021
Annual update about health conditions, medications, permission for OTC medications in school and screening exemptions
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Email *
Last Name *
First Name *
Date of Birth *
MM
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DD
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YYYY
Grade *
Name of parent completing form *
FOOD ALLERGIES (IF NONE, ENTER "NONE") *
DRUG ALLERGIES (IF NONE, ENTER "NONE") *
OTHER ALLERGIES (IF NONE, ENTER "NONE") *
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). *
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 AND/OR IMMUNOCOMPROMISED (I.E. CROHNS, DIABETES, HYPOTHYROID, CELIAC DISEASE, AUTOIMMUNE DISORDERS, GHD, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
ANY CURRENT OR PAST PSYCHOLOGICAL DISORDERS (I.E. ADHD, DEPRESSION, ANXIETY, EATING DISORDERS, ETC.). IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
HAS THE STUDENT HAD ANY HOSPITALIZATIONS IN THE LAST YEAR? IF YES, PLEASE EXPLAIN. IF NONE, PLEASE ENTER "NONE". *
DOES THE STUDENT WEAR GLASSES? *
PLEASE LIST ALL MEDICATIONS THE STUDENT CURRENTLY TAKES, INCLUDING NON-PRESCRIPTION. IF NONE, PLEASE ENTER "NONE". *
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): *
Required
EXEMPTION FROM STATEWIDE SCREENINGS/OPT OUT (see Section 2 below for details) Check all that apply *
Required
NAME AND NUMBER OF PEDIATRICIAN *
NAME OF NUMBER OF DENTIST *
NAME AND NUMBER OF PSYCHOLOGIST/THERAPIST, IF SEEING ONE, IF NOT PLEASE ENTER "NONE". *
*Statewide Screenings
If your daughter has an annual physical and these screenings are being done, please exempt her above. There is no requirement for proof that the assessment was done privately (other than our standard required health forms).
It is expected that students are assessed/screened for height, weight, blood pressure, hearing, vision and scoliosis as needed by their healthcare providers at their annual physical. The state requires school nurses to assess all students to ensure that students who lack consistent healthcare are screened for possible issues. However, parents have the option to exempt their children because it is already being done by their private healthcare provider. Unless parents opt out, screenings are mandated in all grades annually for height, weight, and blood pressure. 9th and 11th are also screened for scoliosis, 10th for vision, 11th for hearing.
Feel free to contact the School Nurse for more information.
A copy of your responses will be emailed to the address you provided.
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