Fillable Confidential Health Card ENG

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Confidential Health Card ENG

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RevApr2011



CONFIDENTIALHEALTHINFORMATION

Incaseofanemergency,theschoolstaffwillcontact911.

Everyattemptwillbemadetocontactaparent,aguardian,oradesignatedemergencycontact.

STUDENTINFORMATION

Last:First:Middle:



DateofBirth: Gender

M F

Grade

SchoolName:



Doesthestudenthavehealthinsurance?Doesthestudenthavedentalinsurance?

Private MedicalAssistance NoInsurance Y N



CURRENTHEALTHCONCERNS

Pleasecheckthefollowinghealthconcernsthatmayimpactthestudent’seducationalday.ThisinformationmaybesharedwithFCPSstaffasappropriate.

Thestudentdoesnothaveanymedicalconcerns



ADD/ADHD

allergies(chooseallthatapply)



foods______________________________________



beesting/insectbite_________________________



medicines__________________________________



pesticides/chemicals*________________________



other______________________________________

asthma:Hasthestudentexperiencedanasthmaepisodein

thepast12months?

Yes No

blooddisorder________________________________



cancer

diabetes

hearingproblems hearingaid(s)

heartproblems_______________________________

mentalhealthdiagnosis_________________________

physicaldisability______________________________

seizures

visionproblems_______________________________



glasses contacts

other_______________________________________

Thisinformationisachangeinhealthconditionfromthelastschoolyear



*FCPSusestheIntegratedPestmanagementprogramstoidentifyandcontrolpestproblemsinschools.Elementaryschoolsmustnotifystaffand

parents/guardiansofallstudents24hoursbeforepesticidesaretobeappliedinsidetheschoolbuildingoronthegrounds.Middleandhighschools

mustnotifyonlythoseparents,guardiansorstaffwhohavefiledawrittenrequestfornotification;formsareavailableateachschoolandmustbe

updatedeveryschoolyear.SeetheFCPSCalendarHandbookfordetails,orcontactyourchild’sschool.



MEDICATIONS

Listallmedicationsanddosagesyourchildreceivesonaroutinebasis

Medicationsarenotrequiredatschool

Ifthestudentrequiresover‐the‐counterorprescriptionmedicationsortreatmentsatschool,thehealthcareproviderandparentmustcompleteand

submittheappropriateauthorizationform(s).Obtainformsfromthehealthstaffatyourchild’sschoolorathttp://www.fcps.org/(clickonForms).



Medications:__________________________________________________________________________________________________________

__________________________________________________________________________________________________________



Iherebygiveauthorizationandconsenttotheschool,intheeventthatIcannotbecontacted,toobtainemergencymedicalcareandnecessary

emergencytransportationtoahealthcarefacility.Iunderstandandauthorizethatmychild’smedicalrecordsorothermedicalinformation,

furnishedtotheschool,willbesharedwith

FCPS/FrederickCountyHealthDepartmentstaffandemergencypersonnelwhohavealegitimate

medical/educationalpurposeforaccessingsuchmedicalrecordsandinformation.

Parent/Guardianname(pleaseprint):_________________________________________________PrimaryContactPh#_____________________



SignatureofParent/Guardian:____________________________________________________Date_______________________



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Completed 23 June 2021

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