Outdoor School Health Update

 

OUTDOOR SCHOOL HEALTH UPDATE

2021-2022 School Year


Student Name:_________________________________________________________________________________________


Date of Birth:__________________               Outdoor School Section:____________________________


SPECIAL HEALTH CARE PLANNING My child has NONE of these concerns/conditions listed below.

Diabetes-  Type 1▢    Type 2 ▢            My student has:         ▢ insulin pump           ▢ insulin pen       ▢ injected insulin 


Seizure Disorder- My student needs emergency medication for Seizures.  Yes▢    No▢

    Name of medication:___________________________________________________________________________


Asthma:

              Yes▢    No▢       Does your child use a rescue inhaler routinely for asthma symptoms?

              Yes▢    No▢       Does your child require an inhaler prior to P.E. class? 

              Yes▢    No▢      Will your child be self-carrying their inhaler (secondary students only)?


Allergy/Anaphylaxis -*Severe, with EpiPen/Auvi Q prescription (example: food, insect stings)

    Allergen(s):____________________________________________________________________________________________

                Yes▢    No▢     Will your child be self-carrying their Epinephrine?


*If you answered yes to any of the above conditions, please provide the nurse with your child’s Prescription and the Emergency Care Plan from the Physician.



HEALTH CONDITIONS My child has NONE of these concerns/conditions listed below.


▢ Asthma


▢ADD/ADHD


▢Seasonal Allergies


▢Arthritis/Rheumatic 





▢Cystic Fibrosis


▢Cardiovascular 





Condition 




▢Blood Disorder


▢ Cerebral Palsy


▢ Sickle Cell


▢ Spina Bifida


▢Tourette’s Syndrome


▢ GI disorder


▢ Other (please list):


The school doctor has written standing orders for the following medications. Please circle yes to give the school nurse permission to administer the following medications as needed:


Acetaminophen (Tylenol)

Yes 

No

Anbesol topical

Yes

No

Antacid

Yes

No

Burn Cream gel/spray

Yes

No

Benadryl (Emergency only)

Yes

No

Caladryl Lotion

Yes

No

Hydrocortisone Cream

Yes

No

Ibuprofen (Motrin/Advil)

Yes

No

Moisturizing Eye Drops

Yes

No

Sting Relief Spray/Towelette

Yes 

No




I do not wish for my child to have any of these medications









Parent 




 Signature_______________________________________________________________________Date___________________







I give the school nurse permission to share health concerns/conditions with pertinent school staff (Initial here)_________ 








Revised 3/2022



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