Gallatin County Schools
Health Information & Emergency Treatment Form
Student’s Name _______________________ DOB ____________ Grade ______
Does your child now or has he/she suffered in the past from any of the following illnesses, disorders or symptoms?
If yes, please explain and give the date of diagnosis/date of last event.
YES
NO
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___ Asthma _____________________________________________________________________________
Diabetes ___________________________________________________________________________
___ ___
Migraines/Frequent Headaches _________________________________________________________
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Cardiovascular (Heart) Disease _________________________________________________________
___ ___
Epilepsy/Seizure Disorder ______________________________________________________________
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Kidney Disease ______________________________________________________________________
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Hepatitis or other Liver Disease _________________________________________________________
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Anxiety/Panic Attacks _________________________________________________________________
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ADHD (Physician diagnosed) ___________________________________________________________
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Autism (Physician diagnosed) __________________________________________________________
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Drug/Latex/Food/Insect Allergies________________________________________________________
Please list all medications your child takes-either daily or as needed-including those taken at home on the back
of form. Please include medication for ADHD, allergies and asthma.
A PERMISSION FORM FROM YOUR DOCTOR MUST BE ON FILE WITH THE
SCHOOL NURSE FOR ALL PRESCRIPTION MEDICATIONS.
The following First-Aid supplies are kept on hand. Please indicate with a check those that
may be used for your child as needed.
______ Caladryl
______Benadryl Cream
______Orajel
______ Antibiotic Ointment
______ Vaseline
______ Hydrocortisone
I hereby authorize Gallatin County Schools and its representatives to consent and obtain emergency medical
treatment of my child, ___________________________________, in case of any illness or injury in connection
with a school activity or school trip.
_______________________________________Signature
_________________________ Date
CURRENT MEDICATIONS
Medication
Dose
Daily
As Needed
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