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Pitt County Schools
2014-2015 STUDENT HEALTH INFORMATION
Grades Pre- K thru 12
An Important Message From Your Child’s School Nurse:
In order for the school nurse to have the most current health information on your student and to help your
student have a healthy and successful year, please complete, and return this form to the teacher or school nurse
by September 5, 2014. If you have any questions completing this form or need to talk with your school nurse,
please do not hesitate to contact the school office and ask to speak with the school nurse. Thank you for your
cooperation!
CHILD’S HEALTH INFORMATION (to be completed by parent/guardian):
Date of Birth
Child’s First Name
Child’s Last Name
(month/day/year)
Parent/Guardian’s
First and Last Name
Telephone Numbers
(daytime numbers)
Home –
Work –
Cell -
Homeroom
Teacher
School
Street Address
Grade
City / Zip
E-Mail Address
Bus or Car Rider
Bus Number (if bus rider)
Physician’s Name / Telephone #
Dentist’s Name / Telephone #
Specialist’s Name / Telephone #
INSURANCE INFORMATION:
Does your child have Medicaid?
Yes
No
Health Choice?
Yes
No
Private Insurance?
Yes
No
Uninsured?
Yes
No
PERMISSION STATEMENT:
I give my permission for the school nurse to share or receive health-related information needed to care for my
above-named child with other healthcare providers (for example doctors, specialists, case managers) during the
2014-2015 school year. The purpose of exchanging this data shall be for diagnostic/educational purposes only. I
understand that I may revoke this consent at any time, except to the extent that action based on this consent has
been taken. This authorization is fully understood and is made voluntarily on my part.
Signature of Parent / Legal Guardian
Date
It is the responsibility of the parent/guardian to notify the school nurse of any changes in the
student’s health status during the school year.
Does your child have a chronic/ongoing health condition?
___ *Yes *IF YES, PLEASE CAREFULLY READ AND COMPLETE THE BACK OF THIS FORM
__ No
Check any of the conditions below that a physician has diagnosed your child as having:
____ ADHD
____ ASTHMA
Does your child have asthma and need an inhaler at school:
YES
NO
If YES, you MUST provide: Medication Authorization Form, Rescue Inhaler, Spacer and Asthma Action Plan
____ SEVERE ALLERGIES
Does your child have an EpiPen/Twin Jett/AuviQ (or other medication) for a life threatening allergy? YES NO
If YES, you MUST provide: Medication Authorization Form and Emergency Medication.
If yes, what is your child allergic to? ___________________________________________________
List emergency medications: _________________________________________________________
____ CARDIAC (Heart) CONDITION
____ CANCER/ LEUKEMIA
____ DIABETES: (please circle) TYPE I or TYPE II
(Parent must provide Diabetes Care Plan from Physician for medication/procedures at school)
____ DIETARY RESTRICTIONS (Parent must provide Diet Order from Physician)
____ POTS (Postural Orthostatic Tachycardia Syndrome)
____ SEIZURE DISORDER/ Epilepsy
____ SICKLE CELL ANEMIA
____ OTHER
Please List: ________________________________________________________________
Does your child:
Take prescription medication(s) at home daily?
Yes
No
Name of medication(s): ____________________________________________________________________
Take medication(s) at school?
Yes*
No
Name of medication(s): ____________________________________________________________________
*Medication Authorization Form required for medications taken at school, including over the counter medications taken
for more than one week.
Need a medical procedure performed at school?
Yes*
No
Type of procedure: __________________________________________
*Authorization for Specialized Health Care Procedure Form required for procedures performed at school.
Need special restrictions or accommodations at school?
Yes*
No
Explain: ___________________________________________________
*Doctor’s note required for special restrictions or accommodations.
Forms are available from your school nurse, your doctor’s office, or the Pitt County Schools website.
It is the responsibility of the parent/guardian to notify the school nurse of any changes in the
student’s health status during the school year.