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▢ 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.
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