Child Health Information Nottingham School Child's Name: _______________________________________ Date of Birth: ___________________ Grade: ___________ Please note that the information on this form is documented on your child’s school health record and the school nurse will share this information with the appropriate school staff as needed.
1. Does your child have allergies? ______No ______ Yes
(IF YES: What? Please check belowand note treatment.) ____Food _____________________________________________________________________________________ ____Bee/stinging insects________________________________________________________________________ ____Medication ________________________________________________________________________________ ____Environmental _____________________________________________________________________________ ____Other ____________________________________________________________________________________
2. Does your child take any medicine on a regular, ongoing basis? ______ No ______ Yes Name of Medication Reason for Taking Special Instructions for
3. Does your child have any issues with vision and/or hearing or do you have any concerns? ______No ______ Yes
(IF YES: please check below and describe.)
_____ Vision (for example, wears glasses for reading) _________________________________________ _____ Hearing (for example, wears hearing aid) _________________________________________
4. In the past year, has your child had any serious illness or injury? ______No ______Yes (IF YES: What? Any special instructions or considerations for school?)
____________________________________________________________________________________________
5. a. Does your child have an ongoing health condition that may affect him or her at school? ______ No ______ Yes
(IF YES: What? Please circle: asthma, diabetes, serious allergy, epilepsy, CF, cancer, heart condition, or other.) ____________________________________________________________________________________________
b. Does this health condition affect your child's learning or participation in activities at school? ______ No ______Yes (for example, fatigue; ability to focus, frequent absences.)
(IF YES: How?)________________________________________________________________________________ 6. Does your child have health insurance? ______ No ______Yes
7. Name of Childs Physician: __________________________________________Phone:__________________________
8. Name of Child’s Dentist: ___________________________________________Phone:__________________________
Consent: I, the parent/guardian of the above named child consent to communication and exchange of health information between the school nurse and my child’s physician and/or dentist regarding immunizations, physical exams, medications and current health status. ______No _____Yes Should a serious illness or accident occur and school personnel are unable to contact parent(s) or guardian(s), permission is granted for emergency medical care to be given as necessary including transport to the nearest hospital. ______No _____Yes Parent / Guardian Signature: _____________________________________ Date: ______________________
Parental Consent for the Administration of Non-Prescription Medication Child's Name: _______________________________________ Date of Birth: ____________ Grade: ____________ Medication Allergies or Sensitivities: _________________________________________________________
I give my permission for my child to receive medication list below on this form as deemed necessary by the School Nurse or School Staff as delegated by the Principal. I understand that the generic equivalent medication may be used. The dose of medication will be as listed on the medication label according to age and/or weight. If your physician has requested a dose above or below this amount, please note the dose on this form. The school nurse does have a supply of these medications. Please check which medications you give permission for your child to receive during the school day.
Publikationen 2010 AGAPLESION Bethanien-Krankenhaus/ Geriatrisches Zentrum an der Universität Heidelberg Publikationen stellen einen wichtigen Beleg für die nationale und internationale Akzeptanz und Würdigung unserer Arbeit am Bethanien –Krankenhaus dar und erfüllen den wichtigen Anspruch an die Forschungsarbeit erbrachte Ergebnisse weiter zu verbreiten und für die geriatris