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Student Annual Health History Form

Please complete this form each year so that our Health Services Department has updated and accurate information in order to best care for our students.

Required

Student Namerequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
What school does this student attend?required
Parent/Caregiver Namerequired
First Name
Last Name

Allergies

Does your child have ANY allergies (food, medication, insect, latex, environmental)? required
Does your child carry an Epi-Pen or nasal epinephrine (neffy)?

Medications

Will ANY medication need to be given at school? This includes all as needed medications such as inhalers, epi-pens, anti-seizure medication or any other prescription or over-the-counter medication. If yes, please contact the school health office. required
Please check any conditions the student currently has or has had in the past:required
Immunizationsrequired
Physical Examinationrequired

Parent/Caregiver Consent for Over-the-Counter Medication:

The administration of Over-the-Counter (non-prescription) medication in Massachusetts schools is regulated by 105 CMR 210.000 and the Board of Registration in Nursing Advisory Ruling 92-05: Medication Administration of Over the Counter Drugs. 
 
Nurses can administer Over-the-Counter (OTC) medications with parent/guardian permission for relief of occasional pain or discomfort. A new form must be completed and signed every school year if you wish your child to receive OTC medications. 
 
Below is a list of over-the-counter (OTC) medications kept in the nurse’s office. You must select each individual item to indicate your authorization. Please do not send medication to school with your child. State regulations strictly prohibit students from carrying most medications to and from school.
Please check below to grant your permission for the school nurse to administer each of the following over-the-counter medications. If permission is not granted by selecting the medication, it will not be given to the student.required
Prescription Medication at School
 
If your student needs prescription medication administered at school or needs to self-carry prescription medication, please complete the forms below and return to the school nurse. Both forms need to be signed by the student's physician.
By electronically signing below I acknowledge the School Nurse will only share information relevant to my child’s health condition with appropriate school personnel on a need to know basis to ensure my child’s health and safety needs.By electronically signing below I acknowledge the school nurse may need to exchange information with my child’s healthcare provider. All information will be kept strictly confidential and used only to provide appropriate individualized healthcare services for my child while in school or school related activity. In the event of illness or injury, the school will make every effort to notify me or the emergency contact on file with the school. In the event that emergency medical care is necessary, EMS will be activated.
Parent/Caregiver Electronic Signaturerequired
Parent/Caregiver First Name
Parent/Caregiver Last Name
Must contain a date in MM/DD/YYYY format