Roanoke Catholic Clinic Information
2014-2015
Name:__________________________
(Preferred)
Grade___
DOB______ M__ F__ (Last)
Acute or Chronic Illnesses: Please mark appropriate circle.
Allergies
None
Drug __________
Food ___________________________
Seasonal _______
Other ___________________________
Describe reaction:__________________________________________________
Treated with Epi Pen
Yes
Treated with Benadryl
Asthma
Yes
Inhaler
Yes
No
If yes Parent must supply Epi Pen
No
No Triggers: __________ Self Carries : Yes
Yes
No
No__ Initial _____
Please provide inhaler for clinic OR note self carry
List home maintenance medications if any ____________________
Please note: All emergency medications must be kept in the Clinic unless the student has a written
order to carry. We require physician authorization and action plans. This policy is for everyone’s safety. Faxed
authorizations are permitted. Action plans available on website.
ADD/ADHD
Anxiety
Diabetes
Gastrointestinal symptoms
Migraines
Seizures
Other ___________________________________
Glasses
Contacts
Hearing device
Orthodontics
Medications
Prescription drugs: Name and condition for use ________________________________
Over the Counter: Name and reason for use ___________________________________
I, ____________________ authorize the school nurse or designated staff member to administer the
below over the counter medications:
Acetaminophen (Tylenol)
Yes
Ibuprofen (Advil or Motrin)
Yes
No
Antacid (Tums)
No
Cough drop/mint
Up to 400 mg Ibuprofen (12yo> for chronic conditions)
Diphenhydramine (Benadryl)
Yes
Yes
Yes
No
Yes
No
No
No (Given for allergic reactions only)
Please Note: Allergy/Cold Medications may be administered if provided by parent with a note. All prescription
medications must be in original containers with clear directions.
First aid treatments used: first aid wash, antibiotic ointment/anti-itch cream, non-latex bandages, Chloraseptic
throat spray, orajel, burn gel, eye wash, hydrogen peroxide and saltine crackers for nausea.
Illnesses/Injuries: Please remember to call each morning to report a student’s absence or tardiness for their
safety!! If the school is not notified we will be calling.
Students are considered contagious with a fever ≥ 100◦. They may not return to school until they have been
without a fever/vomiting/diarrhea and/or have taken antibiotics for 24 hours.
For injuries such as concussions, fractures and other serious illnesses, a physician’s note is required to return to full
participation in PE/sports. Crutches also require a M.D. note.
I authorize the school nurse to contact Dr. ______________regarding health information needed during the
school year.
_________________________________
_________________
Signature of Parent/Legal Guardian
Date
Susan Algeier RNC,BSN
Clinic Hours 9 – 3
Ph: 540.982.3532 x2213, Fax: 540.345.0785
Ruth Peterges RN