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Versailles Exempted Village Schools
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School Health Services: Phone 937-526-4426 Fax 937-526-3480
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Medical History
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Student:
Date of Birth:
Phone:
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Parents:Address:
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Current Conditions (currently requires medication or monitoring) ONone, my child has NO current medical conditions
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OAllergiesReaction: ____________________________________ ODiabetes
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O
Seasonal/Environmental
O
Bee/Wasp
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Food __________
OMigraines
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OMedication ___________________________________________OHeadaches (not migraines)
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O
Has an Epinephrine Autoinjector
O Self-carry OTraumatic Brain Injury
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OSeizures Type: ______________________ Last seizure: __________ OConcussion (when ___________________)
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O
Meds at home
ORescue meds for school OJuvenile Arthritis
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OAsthma Triggers: _____________________________________ OCancer ______________________________
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O
Inhaler for school
OSelf-CarryOMeds at homeOCystic Fibrosis
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OHeart Conditions _________________________________ OSkin Conditions
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ONeuromuscular Disorder __________________________OAttention Deficit/Hyperactivity Disorder
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OBone/Muscle/Joint Problems ______________________OAutism Spectrum _____________________
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OBlood/Bleeding Problems _________________________OSpeech Problems
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OBirth/Congenital Malformations ____________________OMobility Concerns ____________________
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OBehavior Concerns ________________________________OSurgery _____________________________
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OEmotional Concerns _______________________________OPremature @ ___________wks
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OHearing Difficulty/Ear Problems ____________________OIllness/Problems as an Infant (Explain)
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OVision Problems _________________________________OUnusual Birth or Development (Explain)
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Comments:
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History (past health condition requiring care but no longer an issue)O None, my child has NEVER had any medical issues
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List
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Medications (list all prescription & over-the-counter medication your child takes regularly, include vitamins/herbs) O None
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MedicationDoseFrequencyPurposeTaking for how longGiven at home or school
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Accommodations O None necessary
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OMy child has health/medical conditions which require school restrictions, modifications &/or interventions.
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OMy child requires special procedures &/or treatments for their health/medical condition.
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OOther health or developmental information about my child the school should be aware of.
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Explain:
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As parent/guardian, I understand the importance of informing school health services with any changes in my child's medical condition in order for the school to provide the most appropriate care while my child attends school. I also understand the information provided to school health services is confidential and will only be shared with appropriate staff on a need to know basis. If my childs medical conditions, treatments or medications change while in this district, I will contact school health services with updated information as soon as possible.
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Printed Name/Relationship to StudentSignatureDate
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