NDMA Medical Information Form Please fill out completely. Student Name* First Last Birth Date* Month Day Year 2012-2013 Grade Parent's Name First Last Email Phone #1*Phone #2Family Doctor Date of Last Physical Month Day Year Do you have health insurance? Yes No Medical Assistance? Yes No Has your child been ill or hospitalized during the year? Yes No If yes, is he/she still under care of physician? Yes No Are there health services needed in school? Yes No if yes, services needed: Does your child have allergies? Yes No If yes, what? *If your child needs medication at school for allergies, your doctor must sign a permission form.Does your child have asthma? Yes No *If you child needs to carry an inhaler to school, your doctor must sign a permission for.Does your child have a seizure disorder? Yes No Does your child have any heart disease? Yes No Has your child had a history of depression? Yes No Has your child had a history of anxiety? Yes No Is your child taking any medication on a regular basis? Yes No If yes, please name medication and reason:Does this medication need to be administered at school? Yes No If yes, please complete a "Permission to Dispense Medication" form and have it signed by parent and doctor.Has your child had vision problems? Yes No If yes, please explain: Eye Doctor/Date of last exam Has your child had any hearing problems? Yes No If yes, please explain: Audiologist/ date of last exam Does your child have dental problems? Yes No If yes, please explain: Dentist/Date of last exam Does your child have any dietary restrictions? Yes No If yes, please explain: Restrictions in diet must be ordered by your family physician.If yes, please explain: If yes, please explain: Would you like an individual meeting with the school nurse? Yes No When would you like to have this meeting? EMERGENCY CONTACT(If unable to reach parents)Name First Last Relationship Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneName First Last Relationship Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneIf there is any other information, which the nurse will need when caring for your child, please describe here or feel free to call.Medication RemindersIf your child will be taking daily medication, please have permission slip signed by both parent and doctor. ALL medication must be in ORIGINAL container and be dropped off by a parent. The nursing staff does not supply any over the counter medications (Tylenol, Advil, cough drops, etc.) for student use. If your child needs OTC medication in school, please sign the OTC permission form and accompany it with the original container of medication. Care Plan RemindersStudents with asthma, allergies, diabetes, seizures or any other long term medical condition are asked to complete a care plan with medical information to be shared with staff. Please let the nurse in your school know if there are any changes in your child's health.I request that pertinent health information regarding the above student be given to the appropriate school staff at the discretion of the school nurse.Parent Signature Date Month Day Year RELEASE OF INFORMATIONI request that my child's most current HEALTH INFORMATION be released to the Nurse at New Discoveries Montessori Academy.Student Name First Last Date of Birth Month Day Year Clinic Name Parent Signature Date Month Day Year Δ