Your child’s learning depends upon good health. To assist in providing health services at school, please complete the following form. First: Middle: Allergies Reaction Health Care Providers Doctor’s Name: Date of Last Visit: Dentist’s Name: Date of Last Visit: Is child currently under orthodontist care?
Y N Orthodontist Name: Hospital Preference: Medications Please check ALL over-the-counter medications you authorize your child to receive at school. Tylenol/ Acetaminophen (Decongestant, Antihistamine, Cough Suppressant)(Phenlephrine HCL, Bromphiramine maleate, Dextromethorphan)Please list child’s current medications Frequency Reason for taking Will your child require medications at school? Office Use: Attached Medication Form Illness/ Accident/ Hospitalization/ Surgery Please indicate IF and WHEN your child had: Chickenpox: Yes / No Date: ____/____/____ Measles: Yes / No Date: ____/____/____ Mumps: Yes / No Date: ____/____/____ Has your child ever had: Major Illness Serious Accident Hospitalizations Surgeries If yes, please explain providing month and year:_________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Growth Development Did you have any problems during the pregnancy? If yes, Please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Were there any problems at the time of the birth of your child? If yes, Please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Did your child meet the normal developmental stages such as crawling, walking, talking as expected? If no, Please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Health Concerns Chadwick Has your child in the past or present had any problems with the following: If yes, Please explain: Y N Crossed/ Drifting Eyes: Itching/ Burning/ Redness: Excessive Tearing/ Watering: Wear Glasses/ Contacts: EARS/ NOSE/ THROAT Y N Seasonal Allergies: Post Nasal Drip: Sinus Congestion: Frequent Nose Bleeds: Y N Frequent Ear Infections: Difficulty Hearing: Wears Hearing Aid: Right Ear Left Ear Both RESPIRATORY/ LUNGS Chronic Cough/ Chronic Bronchitis: *Asthma: What triggers an asthma attack? *Does your child use an inhaler(s) on a daily basis? Name of inhaler: ENDOCRINE Thyroid Disorder: Diabetes: Y N Do they take insulin? How often is blood sugar checked? LYMPHATIC/ HEMATOLOGY Bleeding Disorder:
Chadwick NEUROLOGICAL Headaches/ Migraines: Seizures: Date of last seizure ____________ Presently under doctor’s care? Currently taking medication for seizures Heart Condition: Heart Murmur: GASTOINTESTINAL Y N Stomach Problems: Diarrhea/ Constipation: Dietary Restrictions: Special Diet: BLADDER/ KIDNEYS Y N Kidney Disorder: Frequent Bladder Infections: Needs to use bathroom frequently: Bed Wetting: Y N Requires Diaper/ Cauterization: BONES/ JOINTS / MUSCLES/ SKIN Rheumatoid Arthritis: Muscle Disorder or Pain: Bone or Joint Disorder or Pain: Y N Skin Disorder/ Scars: Your child’s doctor will need to provide documentation stating restrictions Y N Any Condition that prevents P.E. Participation Office Use: Documentation Provided:
I give my permission for the above health information to be shared with appropriate school personnel on a confidential
I have read the Medication Administration Policy and Procedure Form. I request and authorize Chadwick School to
administer medication to the above student in accordance with the over-the-counter age/ weight specific dosing
____________________________________________________________________ __________________________ Signature
Die Pharmakotherapie hat die weitaus gröûte Be- bare Anzahl von Präparaten beschränken, die erdeutung für die Behandlung von akuten und chro- gut handhaben kann, sowohl hinsichtlich ihrernischen Schmerzen. Es werden dabei nicht nur Dosierung als auch hinsichtlich zu erwartenderAnalgetika eingesetzt, sondern auch unterschied- Nebenwirkungen und deren Prophylaxe bzw. The-liche andere Pharma
City of Milton City of Milton City of Milton I. INTRODUCTION A variety of natural resources are found within the City of Milton that contribute to the social and economic value of the community, and are an important consideration in the planning process. When allowed to function naturally, these resources provide benefits to everyone at no cost; however, when development signifi