Health record form

HEALTH RECORD FORM Student’s Name_________________________________________
Northern Illinois University, Lorado Taft Campus
(815) 732-2111, extension 120
School_________________________________________________
My child will attend the Lorado Taft Field Campus from _______________________to___________________________ Date of Birth ______________ Age______ Weight _______ Male____ Female____ Home Phone____________________ Address___________________________________________________________________________________________ Name of Parent or Guardian__________________________________ Father’s work phone______________________ Guardian’s work phone_________________________ Mother’s work phone_____________________ Alternate Contact name and number ____________________________________________________________________
Our family physician is ___________________________________Physician’s phone____________________________
The answers to these questions will be kept confidential. The purpose of these questions is to provide our nurse
with health and safety information about your child.
IMPORTANT - Please fill in date of last TETANUS BOOSTER_________________________________________
1. See back side of form if child has asthma, an epi-pen or doctor’s excuse from PE activities.
2. Is your child presently under a doctor's care? ____Yes
3. Medical information the Taft nurse should know about. (allergy, illness, physical disability, sleep walker, bedwetter,
etc.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. SPECIAL DIET (vegetarian, diabetic, food allergies, etc.)__________________________________________________
5. MEDICATIONS - I hereby give permission for my child to take medication at Lorado Taft Field Campus under the supervision
of authorized personnel. All medication must be brought in a container appropriately labeled by a pharmacy or physician and clearly
marked with the child's name and instructions for administering. IF YOUR CHILD IS PUT ON MEDICATION AFTER THE
HEALTH FORM IS TURNED IN--SEND A NOTE WITH NAME, INSTRUCTIONS, AND PARENT SIGNATURE.
New protocol requires a doctor’s signed medical note with exact dosages and time of day for any
subcutaneous injections, intramuscular injections or nebulizer treatments. See back side of form.

PLEASE LIST Medication(s)
Directions for administering (specify am or pm) ________________________________________ _____________________________________________ ________________________________________ _____________________________________________ ________________________________________ _____________________________________________
Self-Administering Exception: Students with emergency-use inhalers and epi-pens must carry them at all times.
“OVER THE COUNTER” Medications approved for student (please checkmark each type for approval):
Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Anti-itch cream Cough drops Benadryl allergy tabs
****************************************************************************
I give permission to have my child treated by the Lorado Taft Campus nurse,
or by a physician in case of an emergency.

Signature of parent or guardian______________________________________________ Date__________________
MEDICATIONS TO BE ADMINISTERED BY AUTHORIZED PERSONNEL SHOULD BE GIVEN TO THE
TEACHER/COORDINATOR BEFORE DEPARTURE TO ENSURE SAFE ARRIVAL AT LORADO TAFT FIELD CAMPUS.
SCHOOL MEDICATION AUTHORIZATION FORM
OUTDOOR EDUCATION FIELD TRIP – LORADO TAFT FIELD CAMPUS

IF child is EXCUSED from PE for any reason, YOUR PHYSICIAN NEEDS to fill out, sign this release. MD initials X
Name ____________________________________ has my permission to participate in outdoor education any
limitations must be listed below:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
ASTHMA/INHALER SECTION

Medication/Inhaler ___________________________________________________Dosage _________________q_______________Hours
Neb Treatment – Name/Medication _____________________________________Dosage__________________q_______________Hours

ASTHMA ACTION PLAN Peak flow meter – My Personal Best =

Green Zone – Breathing is easy, can play, work without symptoms PEAK Flow Range 80%-100% of Personal Best
Medication/Nebulizer _________________________________ Dose ________________ Freq _____________ Hours __________________ Yellow Zone – Breathing easy, coughing or wheeze, chest tight, SOB PEAK Flow Range 50%-80% of Personal Best
Medication/Nebulizer _________________________________ Dose ________________ Freq _____________ Hours __________________ Red Zone – Medicine NOT working, nose open wide to breath, breathing is hard and fast, trouble walking and talking, ribs show
IF SYMPTOMS DO NOT GET BETTER – CALL 911 PEAK Flow Range below 50%
Medication/Nebulizer _________________________________ Dose ________________ Freq _____________ Hours __________________
EPIPEN EMERGENCY PLAN SECTION
Please note: each body system must be filled out
Allergic to:
Medication & Dosage:
Epipen 0.3mg Epipen Jr. 0.15mg Twinject 0.3mg Twinject 0.15mg Benadryl 25mg 50mg po
Treatment:
Mouth: Itching, tingling, or swel ing of lips, tongue, mouth ____ EPIPEN ____ TWINJECT ____ BENADRYL
Skin: Hives, itchy rash, swelling of the face or extremities ____ EPIPEN ____ TWINJECT ____ BENADRYL
Gut: Nausea, abdominal cramps, vomiting, diarrhea GIVE ____ EPIPEN ____ TWINJECT ____ BENADRYL
Throat: Tightening of throat, hoarseness, hacking cough GIVE ____ EPIPEN ____ TWINJECT ____ BENADRYL
Lung: Shortness of breath, repetitive coughing, wheezing GIVE ____ EPIPEN ____ TWINJECT ____ BENADRYL
Heart: Thready pulse, low blood pressure, fainting, pale, blueness GIVE ____ EPIPEN ____ TWINJECT ____ BENADRYL
Other: ______________________________________________ GIVE ____ EPIPEN ____ TWINJECT ____ BENADRYL
If reaction is progressing (several of the above areas affected) ____ EPIPEN ____ TWINJECT ____ BENADRYL
CALL 911, CALL PARENTS

OTHER INJECTIONS: Please list below or send a separate physicians order.
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________
_________________________________________
Physician Signature – Date
Parent Signature – Date
(only needed if IM [including Epi Pens, diabetic injections, growth hormones, etc.],
SubQ, nebulizer treatment, excuse from PE or if your school requires it)

Source: http://holmes5thgrade.wikispaces.com/file/view/Health%20form%20June%202011.pdf/373883866/Health%20form%20June%202011.pdf