Healthtemplate

Warwick School District
Annual Health Update
Building __________
Student _________________
Please complete this form and sign on the back at the bottom.
Student Name ___________________________________ Grade _____ Birthdate __________ Address _____________________________________________________ Homeroom/Teacher ______________ Home Phone _______________

Who does this student live with? Both Parents Mother Only

Mother/Stepfather Father/Stepmother Stepfather/Stepmother Foster Parent/s Please list
below:
Parent/Guardian________________________
Parent/Guardian___________________________ Relationship to Student___________________ Relationship to Student_____________________ Email Address __________________________ Email Address ____________________________ Employer_________________________________ Employer’s Telephone____________________ Employer’s Telephone ______________________ Cel Phone _______________________________
Other Adults to be contacted in case of emergency: (attach additional sheet if necessary)
(School officials will not release your child to anyone without proper authorization)
Name________________________________
Relationship to Student__________________ Relationship to Student_____________________ Address__________________________________ Home Phone______________________________ Email Address ____________________________ Employer________________________________ Employer’s Telephone ____________________ Employer’s Telephone _____________________ Cel Phone _______________________________ Are there any court orders on file with the school restricting a person’s contact with the student? Y or N If yes, please list restrictions and provide a copy of the court order: _____________________________________ **********************************
Family Physician _____________________________ Family Dentist _______________________________ Preferred Hospital ____________________________ (Please note that in an emergency, this student wil be transported to the nearest hospital) Medical Information
Does this student have any of the following? (Please explain and provide dates for any YES answers)
Allergies; please list_____________________________________________________________________________
Medication/s your child is presently taking: (list name, dose, frequency, and reason for taking) ________________ _____________________________________________________________________________________________ Immunizations received in the past year? List type, month/day/year: _____________________________________ A serious il ness, injury, or surgery in the past year: ___________________________________________________ A condition requiring ongoing medical care by a health care provider: _____________________________________ Restrictions or limitations from physical activities: _____________________________________________________ A medical condition requiring special seating in the classroom: __________________________________________ Any other health needs or concerns not listed above: _________________________________________________
The fol owing over-the-counter preparations (or generics) may be used to provide first aid treatment to students:
Anbesol, antifungal ointment, Bacitracin or Neosporin ointment, bee sting wipes, Blistex, burn spray or gel,
Calamine or Caladryl lotion, cough drops, Epsom salts, hydrocortisone cream, Neosynephrine, oil of cloves, sore
throat spray, and Visine. These first aid measures include treatment of wounds, bee and insect stings, minor skin
or eye irritations, sore throats, toothaches, nosebleeds, and other illnesses and injuries.
Check one:
( ) I give permission for the nurse to use the above over-the-counter preparations when providing
first aid treatment to my child.

( ) I give permission for the nurse to use the above over-the-counter preparations when providing
first aid treatment to my child, with the following exceptions:__________________________.

May the nurse give your child the standard dosages of the following over-the-counter medications as per the
standing orders from the school physician?

Acetaminophen (Tylenol) Y or N
Naproxen (Aleve) (for ages 12 and up) Y or N
Ibuprofen (Advil, Motrin) Y or N
Calcium Carbonate (Tums, Mylanta) Y or N
Benadryl (for allergic reactions only) Y or N

If you have any health concerns regarding your child, please contact the school nurse. Information related to your
child’s health condition may be shared with appropriate school personnel when necessary to meet your child’s
education, health, and safety needs. Please inform the school nurse of any changes in your child’s health status
throughout the school year.
Signature of Parent/Guardian ________________________ Date: _________________

Source: https://www.warwicksd.org/departmentfiles/0007/healthupdate.pdf