Olympia School District STUDENT HEALTH INFORMATION Nurse Reviewed (Initials) ________
Student’s Name: _______________________________________________ Birthdate: ___________ Gender: ____ Grade: ____ Teacher: ___________
Last First Middle
My student has NO HEALTH CONCERNS at this time
SPECIAL HEALTH CARE PLANNING
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LIFE-THREATENING HEALTH CONDITIONS
NON LIFE-THREATENING HEALTH CONDITIONS MEDICATIONS List any medications taken. A physician’s order is required for
each medication taken. A new order dated after July 1st is required every school year.
Medication: _______________________ For: _________________ Home School
Medication: _______________________ For: _________________ Home School
____ Medication: _______________________ For: _________________ Home School
Medication: _______________________ For: _________________ Home School
CONTACT INFORMATION
Health Care Provider:
____________________________ #: ____________________ Dentist: ______________________________ #:____________________
Parent/Legal Guardian Printed Name Cell Phone Work Phone Additional Number(s) or Email
1.
2.
I consent to the care of my child and to the release of medical information related to my child to school or medical personnel, as needed, to ensure my child’s safety at school. I
understand that it will be my responsibility to arrange for payment for medical care, should my child be ill/injured. I have read and understand this form.
Parent/Legal Guardian Sign Here: _________________________________________________ Date: ___________________
If anything is checked below, please send this form to the school nurse and obtain additional necessary forms. New forms are required each school year dated after
July 1st
Diabetes: Date of Diagnosis: ___________ My student has: Insulin pump Insulin pen Injected insulin
Seizure Disorder requiring Medication: Name of Medication: ________________________________________________________________
Special Health Care Planning: My child has special health care needs such as wheelchair, tube feedings, breathing tube, catheter, intravenous tubes or
other. Please describe condition(s): ____________________________________________________________________________________________
If anything is checked below, please send this form to the school nurse and obtain additional necessary forms. New forms are required each school year dated after
July 1st
Allergy/Anaphylaxis: Severe with EPI-PEN/AUVI-Q prescription (for example: food, insect stings)
Allergens: __________________________________________________ Other:______________________________________________
Asthma: Severe including RESCUE INHALER prescription, hospitalization(s) within the past year, STEROIDS (prednisone) in the past year
(If mild or moderate asthma, see below “NON LIFE THREATENING HEALTH CONDITIONS”)
ALERT TO PARENTS/GUARDIANS: The school must know of LIFE THREATENING conditions (for example: severe allergy with anaphylaxis, diabetes, asthma)
prior to the start of school as these may require an additional plan (per RCW 28A.210.320). Contact your school nurse to begin the process.
ADD/ADHD
Mild/Moderate Allergies
Mild/Moderate Asthma
Blood Disorder Bowel/Bladder Cancer Depression/Anxiety Dental
Hearing Condition Heart Condition Orthopedic/Bone Condition
Social/Emotional/Behavioral Serious Injury Vision Condition Other
Please explain:________________________________________________
_____________________________________________________________
Revised: 2.2020
Please check any of these conditions which your child has or has had:
