All health forms for new and returning students must be submitted by July 15, 2015 . The
Putney School is obligated to request the submission of health forms every year for all students.
** Please note: health forms should not be submitted to Health Services. Please submit all health forms to our electronic medical record company below.
Please use the following checklist to ensure that all required forms are complete before your student arrives:
For parent/guardian/student :

Consent to Administer Medication form

Annual Philosophical and Religious Immunization Exemptions (required by the state of VT, if applicable)

Documentation of Varicella (Chickenpox) Disease (required by the state of
VT, if applicable)

Concussion Policy Acknowledgement form – Student and Parent/Guardian
For health care provider :

Health History and Physical Examination form and immunization record
( required )

Mental Health Report (if applicable)

Prescription Medication and Order Permission form ( required if your child is on prescription medication )

Medical Immunization Exemption (required by the state of VT, if applicable)
Please mail health forms to:
CareFlow, LLC
Attn: Putney Forms
433 West Market St, Suite 6
West Chester, PA 19382
If you have questions for CareFlow
Technical support is available 7 days a week, 7AM to 7PM EST at:
Phone: 610-422-2969 help@careflowemr.com
For questions about health forms
Todd Pinsonneault, Dean of Students tpinsonneault@putneyschool.org
Phone: 802-387-6242

The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
HEALTH HISTORY & PHYSICAL EXAMINATION FORM
To be completed by a licensed medical practitioner not related to the student.
The Putney School requires submission of this physical examination form on an ANNUAL basis.
Student Last Name, First Name:___________________________ Date of Birth (month/day/year):________________
Health History - Check any of the following medical conditions the student has had or is being treated for currently:
ADD/ADHD
Allergies
Anemia
Chronic headaches
Concussion
Depression
Hepatitis
Hernia
High blood pressure
Shortness of breath
Stomach pains
Seizures
Anxiety
Asthma
Chest Pain
Diabetes
Dizziness/fainting
Eating problems
Irregular heartbeat
Loss of eyesight
Menstrual cramps
Weight change (recent)
Weakness
Other
Chicken pox
Chronic cough
Hearing loss
Heart murmur
Mono
Rheumatic fever
List allergies to medications: ____________________________________________________________________
List other allergies: ____________________________________________________________________________
List surgeries with dates: ________________________________________________________________________
List hospitalizations with dates:___________________________________________________________________
Other significant medical conditions: ______________________________________________________________
If any interruption of scholastic career, please state conditions:__________________________________________
____________________________________________________________________________________________
To your knowledge, has this student experienced or been treated for an emotional, behavioral, and/or social difficulty in the past 2 years (e.g., parental divorce, relocation, substance abuse, or other unusually stressful situations)?
Yes ______ No _____ If yes, please describe:________________________________________________________
______________________________________________________________________________________________
Has the student had any emotional symptoms such as mood swings, depression, or unusual degree of anxiety or guilt?
Yes_____ No_____ If yes, please describe:_____________________________________________________________
________________________________________________________________________________________________
To your knowledge, has this student been in the care of a mental health professional(s) in the past two years?
Yes_____ No_____ If yes, a Mental Health Report must be completed by the mental health professional.
Immunizations: Please give date of each required immunization below, and attach information on other vaccinations.
DTap (diphtheria, tetanus, pertussis) vaccine – 5 doses
1 st
Polio vaccine – 4 doses
2 nd
1 st
2 nd
Hepatitis B vaccine - 3 doses
3
3 rd rd
1 st
2 nd
3 rd
Meningococcal vaccine – 1 dose REQUIRED for boarding students
4 th
4 th
5 th
MMR (measles, mumps, and rubella) vaccine – 2 doses
1 st
2 nd
Chickenpox (varicella) vaccine – 2 doses
1 st
2 nd
If the student has previously had chickenpox disease, no vaccine is needed, and parents/guardians may sign the state of
Vermont Varicella Documentation Form. For immunization exemptions, the physician must sign the state of
Vermont Medical Immunization Exemption Form, and a parent/guardian must sign the Annual Philosophical and
Religious Immunization Exemption Form.
(Please see reverse.)

The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
ANNUAL PHYSICAL EXAMINATION FORM
Student Last Name, First Name:___________________________________________________________________
Date of Birth (month/day/year):______________ Male:_____ Female:_____ Other: _____
Physical Exam: Height_____________ Weight _____________ Blood Pressure______________ Pulse ___________
Vision R________ L_________ Corrective lenses?________ Hearing Screen WNL_____ Abnormalities?__________
Are there abnormalities, known injuries, or conditions of the following systems? Please explain in the space provided.
SYSTEM WNL ABNORMALITIES
Head/ears/nose/throat
Eyes
Respiratory
Cardiovascular
Gastrointestinal
Hernia
Genitourinary
Musculoskeletal
Metabolic/endocrine
Neurological/neuropsychiatric
Skin
Any other condition?
Ankle
Knee
Shoulder
Other injury
Any restrictions?
Do you recommend referral to any specialty service? __________________________________________________
Do you envision any need to make provisions and/or limitations in the student’s pursuit of a vigorous academic, extra-curricular, and/or sports/travel program? Yes____ No___ If yes, please describe: ______________________________
_______________________________________________________________________________________________
To your knowledge, has this student been in the care of a mental health professional(s) in the past four years?
Yes _____ No______ If yes, a Mental Health Report (included) must be completed by the mental health professional.
Does student regularly take medication of any type, including psychotropic medication or birth control pills?
Yes_____ No ______ Please list all regularly scheduled medications and complete a Prescription Medication Order and
Permission Form for each prescription medication the student will take while at school. It is important for Health Services to be aware of all medications students are taking in the event of an emergency at school. This includes day students who take medications at home.
________________________________________________________________________________________________
________________________________________________________________________________________________
IMPORTANT: You are asked to urge this student to have remedied, BEFORE ENTERING THE PUTNEY SCHOOL, any condition likely to cause interruption in success at The Putney School program. Please use a separate sheet to include further information or elaborate on any condition above.
Physician signature _______________________________________________________ Date___________________
Physician name (please print) _______________________________________________ Phone_________________

The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
MENTAL HEALTH REPORT
This report is to be filled out by all mental health professionals that have provided services to the student within the past four years (copy form if necessary).
Student Last Name, First Name:___________________________ Date of Birth (month/day/year):______________
To the Mental Health Professional: This student has already been accepted to The Putney School. In an effort to provide the most comprehensive services possible, it is important that we know of any emotional difficulties the student has had, should any mental health issues arise in our rigorous boarding school environment. Thank you for completing the following:
When and for how long did you see the student?
What were the presenting issues and the DSM V diagnosis?
What treatment was provided and how would you assess the outcome?
Was/is medication prescribed and if so, what?
List all hospitalizations:
Hospital Dates Outcome
Signature: ____________________________________________________ Date: ____________________
Please print name: _____________________________________________
License, Title, Degree: __________________________________________

The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
PRESCRIPTION MEDICATION & ORDER PERMISSION FORM
Prescription medication will not be given to students at school until Health Services receives this form completed and signed by the prescribing physician. The medication must be in its original container labeled by the pharmacy as prescribed by the physician. All regularly scheduled medications must be listed here and on the Permission to Treat Form so that, in the event of an emergency, the treating physician is aware of all medications. Please fill out instructions for each medication. The Putney School requires a new form to be submitted each time a medication changes.
Student Last Name, First Name:_________________________________________
Date of Birth (month/day/year):________________
Medication/Dosage Frequency/Directions Reason for taking
Physician name (print please): ______________________________________________________
Physician signature:__________________________________ Today’s Date:_________________
Phone:______________________ Email:______________________________________________

The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
CONSENT TO ADMINISTER MEDICATION
Student Last Name, First Name:___________________________ Date of Birth (month/day/year):________________
MEDICATION POLICY AGREEMENT (ALL PARENTS/GUARDIANS)
I have read and understand the medication policy at The Putney School and agree to abide by its guidelines. I have reviewed the guidelines with my child. I understand that my child cannot possess any medication (over-the-counter, herbal, natural remedies, or prescription) without receiving permission from a school nurse. I am responsible for promptly updating Health Services with any changes in medications or as new medications are prescribed. I understand that that medicine will be disposed of if it is not picked up within one week following termination of the order or one week beyond the close of school. I understand that violation of this policy may result in a disciplinary hearing for my child. Parent/guardian initials Yes_____ No_____
PRESCRIPTION MEDICATION ADMINISTRATION CONSENT (ALL PARENTS/GUARDIANS)
I give permission for Health Services or school personnel designated by Health Services to administer prescription medications prescribed to my child. These medications may include prescriptions my child is currently on or medication prescribed while my child is at school. Prescription medications from home must be accompanied by a
Prescription Medication Order and Permission Form signed by the prescribing caregiver. I understand that a new
Prescription Medication Order and Permission Form is required for every change of medication, dosage, or other instruction. I understand that all prescription medication must be kept in its original pharmacy container with the appropriate label specifying student name, medication, dosage, route, and frequency or time of administration, and other special instructions. Parent/guardian initials Yes_____ No_____
OVER-THE-COUNTER MEDICATION ADMINISTRATION (ALL PARENTS/GUARDIANS)
I give permission for Health Services or school personnel designated by Health Services to administer over-the-counter medications to my child according to guidelines approved by the school physician.
Parent/guardian initials Yes_____ No_____
PARENT CONSENT FOR SELF-ADMINISTRATION OF MEDICATION (ALL PARENTS/GUARDIANS)
I give permission for my child to self-administer medication, provided that Health Services determines it is safe and appropriate. I feel comfortable that my child can responsibly administer him/herself medications. The Putney School can provide support and teaching to students taking medication, but does not assume responsibility for students who self-administer medications (prescription, over the counter, or natural/herbal remedies) as prescribed by a physician.
The option for self-administration excludes all controlled substances, which must be stored according to school policy and administered by Health Services or school personnel designated by Health Services.
Parent/guardian initials Yes_____ No_____
__________________________________________________________
Parent/guardian signature
_____________________
Date
STUDENT AGREEMENT FOR SELF-ADMINISTRATION OF MEDICATION (ALL STUDENTS)
1.
I have read the medication policy and will abide by its guidelines.
2.
I understand that I am responsible for taking medications as directed.
3.
I will safely store the medications and keep it packaged as Health Services directs. I will report lost medication to Health Services immediately.
4.
I agree to contact an adult on campus if I do not feel well, or if I have a question about my medication.
5.
I agree to NEVER share my medication with anyone.
6.
I agree to NOT keep medications in my dorm room or with me unless authorized to do so by Health Services.
7.
I understand that not following these guidelines may result in a disciplinary process.
__________________________________________________________ _____________________
Date Student signature

The Putney School ■ Health Services ■ 418 Houghton Brook Rd. ■ Putney, VT 05346
Phone: 802-387-6221 ■ Fax: 802-387-6228 ■ Email: healthoffice@putneyschool.org
Allergy Injection Policy
Allergy injections are administered at the Brattleboro office of the school physician or at
The Putney School infirmary.
Adverse reactions to allergy injections, though rare, are well-documented in medical literature. These reactions can be life-threatening. Due to the possibility of potentially serious reactions, the student and parent/guardian will be offered the option to have allergy injections administered at the Brattleboro office of the school physician. There will be a transportation fee and physician co-pay, if required by the student’s insurance plan, for this service.
Because the risk of severe reaction is low and because many students have received injections at previous schools, we recognize that some students and parents/guardians may prefer to continue injections at school. This decision must be made with the understanding that there is NO physician on the premises. Health Services staff may administer allergy injections ONLY when there are two registered nurses present in the office. The student will be required to be observed for thirty minutes following the injection(s).
If, after reviewing this policy, considering the implications of having the injections administered at the school, and discussing this with the student’s allergist, I, the undersigned, am willing to assume the risks. This release form must be signed and returned, along with instructions and medications from the prescriber, to Health Services before any injections can be given.
____________________________________________
Parent/Guardian Signature
____________________________________________
Parent/Guardian Name
Date _________________________

The Putney School ■ Health Services ■ 418 Houghton Brook Rd. ■ Putney, VT 05346
Phone: 802-387-6221 ■ Fax: 802-387-6228 ■ Email: healthoffice@putneyschool.org
ALLERGIST CONSENT FORM
The Putney School Health Services (Health Services) provides allergy injections as a service to students and reserves the right to discontinue administration of injections to students who fail to comply with their prescribed regime, or who fail to notify the health office of changes in their regime.
Allergy injections are only to be administered within the following guidelines:
Students must have instructions from their prescribing physician, clearly labeled with the student’s name and the physician’s name, address, and phone number. Instructions must include serum to be used, dosages, and injection intervals. The Putney School nursing staff will consult with the prescribing physician when necessary to clarify instructions.
Students must provide their own serum, which can be stored in The Putney School Health
Services refrigerator.
Due to the increased risk of anaphylaxis, students who have not received allergy injections previously, or who are resuming injections after a four-month layoff, must receive the initial injection at the prescribing physician’s office.
There is no physician available when allergy injections are administered at The Putney
School, however, there will be two registered nurses present during the time allergy injections are given and during the waiting period post-injection.
Individual receiving injections must remain in Health Services for a period of at least (30) thirty minutes after in the injection(s) is/are administered.
At each appointment, before drawing up the injection, the nurse will ascertain if the student has recently been ill, is taking any medications (injection is not given if the student is on a beta blocker), if there have been any reactions to recent injections, or if the dosage schedule has not been adhered to. Health Services will refer to the allergist’s instructions regarding the need to adjust the dosage or delay administration of the injection under these circumstances. Health Services will contact the prescribing allergist for clarification of instructions, if necessary.
Health Services requests specific instructions or a “standing order” for non-compliant students, i.e. students who consistently miss appointments.
Syringes will not be filled until it has been ascertained that there are no contraindications to receiving the allergy injection. Health Services will advise students when they are low on serum. The student is responsible for contacting their allergist for serum refills.
An allowance of one minute between injections is recommended. Documentation on the allergy flow sheet will include the date, dosage, and any reaction that occurred during the

(30) thirty minute interval after receiving the injection. Measurement of any local reaction, i.e. wheal, flare, etc., will be documented on the flow sheet.
Students receiving injections in Health Services will have a section in his/her chart and the Medication Administration Record with the following information:

Current instructions/Schedule for administration of allergy injections

Allergist flow sheet

Allergist consent form
Prior to administration of allergy injections, Health Services must be familiar with the anaphylaxis/allergy response protocol.
The allergy injection guidelines and protocol of The Putney School Health Services is acceptable to me, as prescribing physician for my patient:
Patient Name
Allergy desensitization injections may be administered by the nursing staff at The
Putney School.
Printed Name, Prescribing Physician ______________________________________
Signature, Prescribing Physician ___________________________________
Date _______________________

Management of Physical Activity-Related Concussions
The Putney School has developed this protocol to address the issue of the identification and management of concussions for students who participate in school physical activities.
A safe return to activity protocol (learning and athletics) is important for all students following any injury, but it is essential after a concussion. The goal of this concussion protocol is to ensure that concussed students are identified, treated and referred appropriately for return to learn and return to play. Consistent use of a concussion management protocol will ensure that the student receives appropriate follow-up and/or academic accommodations in order to make certain that the student is fully recovered prior to returning to full activity.
This protocol will be reviewed annually by the school’s consulting physician. Changes and modifications will be reviewed and written notifications will be provided to athletic department staff, coaches and other appropriate school personnel.
All coaches are required to undergo concussion management training every two (2) years.
Parents and athletes must be educated about concussions annually. The written documentation of coaches’ annual training shall be tracked by the director of the
Athletics program, and the student/parental notification will be tracked by the director of
Health Services.
Recognition of Concussion
These signs and symptoms – following a witnessed or suspected blow to the head or body
– are indicative of a probable concussion.
Signs (observed by others)
Forgets plays
Appears dazed or stunned
Exhibits confusion
Unsure about game, score, opponent
Moves clumsily (altered coordination)
Balance problems
Personality change
Responds slowly to questions
Forgets events prior to hit
Forgets events after the hit
Loss of consciousness (not required )
Symptoms (reported by athlete)
Headache
Fatigue
Nausea or vomiting
Double vision, blurry vision
Sensitive to light or noise
Feels sluggish
Feels “foggy”
Problems concentrating
Problems remembering
Any student who exhibits signs, symptoms, or behaviors consistent with a concussion must be removed from competition or practice and will not be allowed to train or compete with a school athletic team or physical activity until the student has been examined by and received written permission to participate in athletic activities from a health care provider (per Act 68, approved by the VT Legislature in 2013).

The registered nurse on duty and/or the coach has been designated as the individual who can make the initial decision to remove a student from play when it is suspected the athlete may have suffered a concussion.
Athletes with a suspected concussion should not be permitted to drive home.
The school must notify parents/guardians within 24 hours if student sustains a concussion.
The registered nurse and/or the coach are the individuals assigned to inform parents/guardians that their student/child may have sustained a concussion.
Act 68 requires that schools must outline the steps required before a student can return to athletic or learning activity.
Return to Learn Protocol : The following steps are required before the student can return to academic activity. The student is required to complete the RTL protocol and be symptom free for 24 hours before beginning the RTP protocol.
Home - Total Rest
Home – Light Mental Activity
School – part time – maximum accommodations: short days, scheduled breaks, modified testing and assignments
School - part time – moderate accommodations: modified testing, increase time in classroom
School – full time – minimal accommodations: routine testing, increase time in classroom
School – full time – full academics, no accommodations
Return to Play Protocol : The return to play plan should start only when you have been without any symptoms for 24 hours. It is important to wait for 24 hours between steps because symptoms may develop several hours after completing a step. Do not take any pain medications while moving through this plan (no ibuprofen, aspirin, Aleve, or
Tylenol). This program should be supervised by an athletic trainer, school nurse or health care professional trained in the management of concussions
Step 1: Aerobic conditioning - Walking, swimming, or stationary cycling.
Step 2: Sports-specific, simple, non-contact drills – skating drills in hockey, running drills in soccer/basketball.
Step 3: Non-contact training drills – include more complex training drills (passing in soccer/ice hockey/basketball. Running specific pattern plays, etc).
Step 4: Full contact practice.
Step 5: Full medical clearance for return to play.
The registered nurse is that person designated by the school to approve the Graded Return to non-contact physical activities.
The school’s consulting physician is the individual who make the final decision regarding the student’s return to athletic activity.

I have received and read concussion information provided to me by The Putney School. I understand the information provided and agree to the following:
1. To report any concussion or concussion-like symptoms that occurs during school activities.
2. To report any concussion or concussion-like symptoms that occurs as a result of injury outside of school.
3. I have read and understand the school policy regarding concussion management and return to activity.
4. I understand that medical clearance after a concussive injury clears the student to start the return to physical activity protocol - not to immediately return to full participation.
Student Name (please print) _______________________________
Student signature _________________________________Date _________________
Year of Graduation _______________
I have received and read concussion information provided to me by The Putney School. I understand the information provided and agree to the following:
1. To report any concussion or concussion-like symptoms that occurs during school activities.
2. To report any concussion or concussion-like symptoms that occurs as a result of injury outside of school.
3. I have read and understand the school policy regarding concussion management and return to activity.
4. I understand that medical clearance after a concussive injury clears the student to start the return to physical activity protocol - not to immediately return to full participation.
Student Name (please print) _______________________________
Student signature _________________________________Date _________________
Year of Graduation _______________ (Please see reverse)