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Nash-Rocky Mount Public Schools
Student Health Services
Student
Heart Condition
Individualized Health Plan
Date of Birth
Grade
Parent/Legal Guardian
School
Emergency phone numbers
Teachers
Valid for School Year
To be completed by Healthcare Provider

Innocent/Benign/Flow Murmur – No medical intervention/care, medication, or limitation of activities.
Structural Murmur – May require medical intervention/care, antibiotics before dental procedures, medication, and/or
limitation of physical activity.
Bicuspid Aortic Valve (click)
Marfan Syndrome
Mild Aortic Stenosis
Mild Pulmonic Valve Stenosis
Mitral Valve Prolapse
VSD
Small PDA

Irregular Rate or Rhythm
Supraventricular Tachycardia (SVT) Bradycardia
Other (specify)
 Other Cardiac Condition (describe)
Age of Diagnosis:
Date of most recent appointment with heart doctor:
 Antibiotics needed prior to dental procedures:
 Yes
 No
Echocardiogram: Yes No Date: ______________ Comments:
EKG:
Yes No Date: ______________ Comments:
Other Tests – List:
Date:
Comments:
PE/Recess Restrictions needed at school? Yes No (If yes, signature required by healthcare provider.)
List restrictions:
Additional comments:
Healthcare Provider Signature
Print Name
Phone
FAX
To be completed by Parent/Legal Guardian
Comments regarding your child’s health:
Parent/Legal Guardian Signature:
Date:
To be completed by School Nurse
Comments:
School Nurse Signature:
File original in Individual Health Record. Copies to appropriate staff and Emergency Action Plan Notebook
Date
Revised: October 2014
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