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HEALTH HISTORY FORM and RELEASE of INFORMATION ~ SCHOOL YEAR 20_____ (Official Use Only) ANCHORAGE SCHOOL DISTRICT Student ID_______ STUDENT HEALTH HISTORY FORM AND RELEASE OF INFORMATION ~ SCHOOL YEAR 20_____ (official use only) Student Name (print first) (print last) DOB Grade M F Your student’s health history is important to provide the best care at school. It is the responsibility of the parent /guardian to notify the school of new or existing health concerns. If your student is prescribed medication or requires a treatment at school, it is the responsibility of the parent or guardian to notify the school and provide the medication or necessary equipment for use at school. *Release of Information: The disclosure of health information within the school is limited to information necessary to serve the student’s health and education interests. Your voluntary agreement gives permission for the nurse to inform school staff of precautions and procedures necessary to protect your child at school and foster academic success. I Agree I Disagree Parent/Guardian Signature Date_________________ My student has the following (NEW or EXISTING) medical condition(s). Additional listing provided on BACK PAGE. (Check all that apply) HEAD Perforated Tympanic Osteoporosis Anaphylactic/peanuts Brain Injury Membrane (hole in eardrum) Rheumatoid Arthritis/Juvenile Anaphylactic/stings Concussion (loss of Speech Problems Scoliosis Lactose Intolerance consciousness) Swallowing Problem ENDOCRINE/BLOOD EMOTIONAL/BEHAVIORAL/ Concussion (no loss of Tracheostomy Clotting Defect PSYCHOLOGICAL consciousness) HEART/LUNGS/BRAIN Diabetes/Insulin Dependent ADD Epilepsy Arrhythmia Diabetes/Type II ADHD Migraines (diagnosed) Asthma, Asthmatic Hemophilia Anxiety Seizure Cystic Fibrosis Neoplasm (cancer) Asperger’s EYES Heart Murmur Sickle Cell Autism Astigmatism Hypertension SKIN Bipolar Color Blindness Genetic Rheumatic Fever Dermatitis/Chronic Developmental Delay Glasses/Contacts Stroke Eczema Depression Myopia (nearsighted) ABDOMEN/INTESTINAL/ Psoriasis Eating Disorder Nystagmus (involuntary eye URINARY Urticaria, Cold/Heat Mood Disorder movements) Colostomy ALLERGIES Obsessive Compulsive Vision Loss/both Constipation Allergy, Airborne Oppositional Defiant Disorder Vision Loss/one eye Crohn’s Disease Allergy, Animals Post Traumatic Stress EAR/NOSE/THROAT/ Encopresis (bowel incontinence) Allergy, Drug Psychiatric Disorder MOUTH/NECK Enuresis (urinary incontinence) Allergy, Food/eaten Schizophrenia Acute Suppurative OM Gastroesophageal reflux Allergy, Food/skin CHROMOSOME/GENETIC Hearing Aid Gastrostomy (GT) Allergy, Latex Down Syndrome Hearing Loss/Condition BONE/MUSCLE/JOINT Anaphylactic Shock OTHER OtitisM(acute/chro)NonDraining Muscular Dystrophy Anaphylactic/foods Fetal Alcohol Syndrome Osteopenia Anaphylactic/nuts I f a medical condition(s) is not listed ABOVE or on the BACK PAGE, check this box AND follow up with your School Nurse: Other Diagnosis not listed (If this box is checked, you must follow up with School Nurse regarding the student’s medical condition(s).) If your student DOES NOT have any (new or existing) known allergies or medical condition(s), check this box: My Child has NO (new or existing) health concerns. (If this box is checked, you agree to communicate with the School Nurse regarding new health concerns during the school year.) My child will require the following medication types given My child will require the following medication(s) at school during the school day (Check all that apply) (Check all that apply) *Homeopathic & herbal remedies cannot be given at school. * Epi‐pen (Parent or Guardian MUST provide epi‐pen) Long‐Term Prescribed Medication Antihistamine (Benadryl) The Long‐Term form must be completed by the parent/guardian AND Inhaler healthcare provider: MD/DO/ANP/PA & medication delivered in a properly labeled pharmacy container. My child will require the following plan or other treatment Short‐Term Prescribed Medication at school (Check all that apply) The Short‐Term form must be completed by parent/guardian & medication Student Allergy/Anaphylaxis Action Plan delivered in a properly labeled pharmacy container. Asthma Action Plan Diabetes Care Plan OTC/Over the Counter Medication Diabetes Care Plan with pump To have an Over‐The‐Counter medication at school, a parent must complete Seizure Action Plan a separate form and provide medication in the original container. Other treatment in school Anchorage School District Health_History_SY11‐12_print_version.pdf School Nurse Health Manual Revised 05/2011 NTD, K, 5, 9 Page 1 of 2 ANCHORAGE SCHOOL DISTRICT Student ID_______ STUDENT HEALTH HISTORY FORM AND RELEASE OF INFORMATION ~ SCHOOL YEAR 20_____ (official use only) Student Name (print first) (print last) DOB Grade M F USE THIS SIDE IF YOUR CHILD HAS A MEDICAL CONDITION(S) NOT LISTED ON FRONT PAGE (CHECK ALL THAT APPLY) Parent/Guardian Signature Date_________________ Head Alopecia (hair loss) Mitral Valve Prolapse Fibromyalgia Allergy/insect Disfigurement/Head Pacemaker, Cardiac Legg‐Calve'‐Perthes Emotional/Behavioral/ Encephalitis (Brain inflammation) Paroxysmal Tachy (AV) Myasthenia Gravis Psychological Epilepsy/Clonic/Tonic Patent Ductus Arteriosus Osteochondritis Dissecans Anorexia Epilepsy/Jacksonian Pulmonary Hypertension Osgood‐Schlatter Bulimia Epilepsy/Petit mal Pulmonary Stenosis Osteogenesis Imperfecta Dysthymia Febrile Seizure Pulmonary Tuberculosis Osteosclerosis Emot/Beh/Mental Health Hydrocephalus Suctioning/aspirator Paralysis, Paralytic Manic/Depressive Meninges Tumor/Benign Tachycardia Paraplegia Narcolepsy Shunt Tuberculosis Miliary Rhabdomyosarcoma Obesity Eyes Transposition Great Vessels Spinal Muscular Atrophy Pica Amblyopia (lazy eyes) Vasovagal Syncope Tic Retardation & Development Artificial Globe Ventricular Septal Defect Endocrine, Blood Trichotillomania Color Blindness Congenital Ventricular Tachycardia Abnormal glucose Chromosome/Genetic Congenital Cataracts Wolff‐Parkinson‐White Anemia Arnold‐Chiari Malformation Duane’s Retraction (eye Syndrome Diabetes Insipidus Cornelia de Lange Syndrome movement disorder) Abdomen/Genito‐Urinary Diabetes/Diabetic DiGeorge Syndrome Esophoria (eyes turn inwards) Bladder Extrophy Diamond‐Blackfan Anemia Fragile X Syndrome Exophoria (eyes turn outwards) Celiac Disease Diseases of Blood Kartagener's Syndrome Glaucoma, congenital Chronic Renal Failure Galactosemia Klinefelter's Syndrome Hypermetropia (longsighted) Colitis Graves’ Disease Klippel‐Feil Syndrome Intraocular lenses Cystic Disease Medulla Growth Hormone Deficiency Marfan's Syndrome Ptosis (drooping eyelid) Dialysis, Renal Hodgkin’s Disease Mobius Syndrome Retinitis Pigmentosa (damaged Duodenal Spasm Hyperthyroidism Nager S/Macrocephaly retina) Dysmenorrhea Hypoglycemia Neurofibromatosis Retinoblastoma Dyspepsia (impaired digestion) Hypopituitarism Phenylketonuria/PKU Retinoschisis, Juvenile Esophageal Reflux Hypothyroidism Prader‐Willi Syndrome Stargardt's Disease (early macular Esophagus stricture Leukemia, lymphoblastic Sensory disorders degeneration) Gastroschisis Lymphoma (malignant) Soto's Syndrome Ear/Nose/Mouth/Throat/Neck GT/Stoma Malfunction Precocious Puberty Spina bifida Bell’s palsy (facial paralysis) Hepatitis Raynaud Syndrome Trisomy 13 Cervical Joint Disease Hepatitis B Carrier Spherocytosis Trisomy 18 Cleft Palate Hepatitis C Carrier Thalassemia Turner's Syndrome Epistaxis (nosebleed) Hiatal Hernia Thrombocytopenia Waardenburg's Syndrome Hearing/Condition Hirschsprung’s Disease Vasculitis Other Sensorineural Ileostomy Vascular device/implant Budd‐Chiari Syndrome Meniere's Syndrome (inner ear Irritable Bowel Syndrome Von‐Willebrand Disease Cytomegalic Inclusion Disease disorder) Jejunostomy Skin Drainage Device Microtia (small outer ear) Kidney Removed Acne Dwarf/Achondroplasia Pain, neck Kidney Transplant Albino Dyslexia Polyp, larynx Nephritis Dermatitis/Cold Dyspraxia Respirator dependent Nephrotic Syndrome Dermatitis/Diaper Erb's palsy Trach/Obstruction Neurogenic Bladder Dermatitis/Impetigo Hemorrhoids Trach/Stoma Problem Polycystic Kidney Dermatitis/Metals HIV Disease Tracheomalacia Short Bowel Syndrome Dermatitis/Seborrhea Hypogammaglobulinemia Vertigo (dizziness) Suprapubic Catheter Dermatitis/Simplex Immunodeficiency Transplant, Liver Heart/Lungs/Brain Dermatitis/Zoster Lupus Ulcer, Gastric Henoch Schonlein Syndrome Aortic Stenosis Motor problems/head Ulcer, Peptic Lichen Sclerosis Atrial Septal Defect Motor problems/limbs Wilms' Tumor Pseudoxanthoma/Keratosis Breathing Exercises Other vein problem Breathing, Bronchial Bone/Muscle/Joint Scleroderma Spastic Hemiplegia Bruit Amputation below knee Staph Infection Unspecified Stone's Syndrome Arthritis, Chronic Varicella Congestive Heart Failure Tourette Syndrome Arthrogryposis Warts Cardiac Valve Disease Wheelchair Cerebral Palsy Cardiomyopathy Allergies Hemiparesis Chronic Fatigue Syndrome Allergy, Other Kawasaki Disease Fibrodysplasia Ossificans Allergy/grass Anchorage School District Health_History_SY11‐12_print_version.pdf School Nurse Health Manual Revised 05/2011 NTD, K, 5, 9 Page 2 of 2 .
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