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Student medical info-rev. 03.2008-

Sahuarita Unified School District #30
STUDENT MEDICAL INFORMATION
School Year 20____- 20_____
All students must have completed form on file EVERY YEAR. Information will be stored in Student Health Records and will be confidential to the greatest extent allowable by law. Does your child have any medication, food, or other ALLERGIES? Please list all allergies and reactions:
____________________________________________________________________________________________________
Does your child have any of the following conditions? (Check all that apply and describe below.) r   YES    r    NO  
Asthma  
r    YES    r    NO  
Gastrointestinal  Disorder  
_______________________  
r    YES    r    NO  
Diabetes  
r    YES    r    NO  
r    YES    r    NO  
Seizure  Disorder  
r    YES    r    NO  
Wears  Glasses/Contacts  
r    YES    r    NO  
Heart  Condition  
r    YES    r    NO  
Wears  Hearing  Aid  
r    YES    r    NO  
Pacemaker/Defibrillator  
r    YES    r    NO  
Other  Vision/Hearing  Problem  
___________________  
r    YES    r    NO  
Heart  Monitor  
r    YES    r    NO  
Had  Chicken  Pox,  Date  (Mo/Yr):_________________  
r    YES    r    NO  
Kidney  Disease  
r   YES    r    NO  
Other:  
_______________________________________  
Please Describe: _______________________________________________________________________________________________________________ Does your child take medications regularly? Please List: __________________________________________________________________ MEDICATION POLICY
All medication must be brought in original containers. Written parental permission must accompany all medicine, regardless if it is
prescription or non-prescription. Written doctor’s orders must accompany all medications with the following exceptions: TYLENOL,
CALAMINE LOTION, BENADRYL, BLISTEX, AMBESOL, TUMS, SORE THROAT SPRAY, HYDROCORTISONE CREAM and
TOPICAL ANTIBIOTICS, such as BACITRACIN OINTMENT (to be used at the discretion of the District Nurse, Health Assistant, or
personnel trained by the nurse for individual instances). Regular use of these and any non-prescription medications will require written
physician’s orders.
Please Check (ü) and initial the appropriate box(es).
Give permission for the District Nurse, Health Aide, or other personnel trained by the District Nurse to administer the above noted medications, in a given situation. I understand that any request for regular administration of prescription and non- prescription medications must be accompanied by written parental and physician I understand the risks of Toxic Shock Syndrome and I give the Health Office permission to give my female high school student tampons, as needed during her menstrual cycle.
EMERGENCY CONTACTS: The following individuals may be contacted in the event of an emergency or illness when parents can
not be reached, and have permission to pick my child up from school:

_________________________________________ _______________________________________ _________________________________________ Page 1 of 2

In case of an emergency, the nurse, principal, or an authorized designee shall call for emergency medical service. The
individual patient (parent/guardian) will be responsible for incurred costs of transportation and medical service.
Parent/Guardian’s choice of hospital: 1) _______________________________ 2) _____________________________
Child’s Doctor:
Insurance carrier: _________________________________________________________________________ Please initial one. __________ YES __________ NO Permission is hereby given for emergency treatment by a physician if parent/guardian contact I have read and understand the information regarding medical/health procedures.
Parent/Guardian Signature
Page 2 of 2

Source: http://www.susd30.us/docs/CVES/StuMedInfo.pdf

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