CHRONIC ILLNESS VERIFICATION FORM
Student: ____________________
DOB: ___/___/___
Grade: ______
Forward to: _________________________
____________________
School
Fax Number
Dear Physician,
Your patient is a student enrolled in the North Marion School District. For our records, please list the
chronic illnesses diagnosed for the student. Also, please check or list the symptoms that would not warrant
an office visit, but might require the child to stay home from school. This will allow the parent to verify
illnesses, by listing in writing to the school the symptoms designated below without bringing the child to
your office for an examination. This document expires at the end of the academic year it was received.
Physician signature: _____________________________
Date: ___/___/___
*An attached business card or letterhead is required.
Chronic Illness/Medical Diagnosis: ____________________________________________________
Symptoms: _____________________________________________________________________
Expected Frequency: ___________ of episodes (ie: monthly, 4 times per school year)
Length of absence per episode: _____ day(s)
Neurological system
__lethargy
__dizziness/unsteadiness
__numbness in extremities
__petit mal seizures
__grand mal seizures
__severe headache
__blurred vision
Respiratory system
__ weakness/fatigue
__pallor/cyanosis
__continual coughing
__congested airway
__difficulty breathing
Integumentary system
__skin lesions
__infections
__edema
Cardiovascular system
__weakness/dizziness
__pallor/cyanosis
__palpitations
__rapid pulse
__arrhythmia
__pain
Genitourinary system
__menstrual complications
__bladder/kidney infection
Gastrointestinal system
__ nausea/vomiting
__diarrhea
__constipation
__abdominal pain
Musculoskeletal System
__ inflammation/swelling
__pain
Ear, Nose & Throat
__severe allergies
__severe asthma
__fever
__pneumonia/bronchitis
__chronic infections
__fevers/ infections
Additional Comments: ______________________________________________________________
__________________________________________________________________________________
* To be filed in school attendance office
Chronic Illness Verification 5/23/11
AUTHORIZATION FOR EXCHANGE OF INFORMATION
To: ____________________________________________________________________
Physician’s name
____________________________________________________________________
Physician’s address
I hereby request and authorize the exchange of information on the following chronic
illness/medical diagnosis:
__________________________________________________________________
pertaining to my child between the North Marion School Administration and:
__________________________________________________________________
Physician’s Signature
I request North Marion School District to contact the parent/guardian signing this authorization
before contacting the authorizing medical professional ____ (initial here
to request).
This contact will only be made if the frequency or length of absences exceeds the numbers
authorized above.
I further understand with this verification that I must notify the school
attendance office upon each absence.
_________________________________________________
Parent/Guardian Signature

__________________
Date
To be filed in Physician’s office
Chronic Illness Verification 5/23/11