MESD OUTDOOR SCHOOL Teacher____________________________ 11611 NE Ainsworth Circle School______________________________ Portland, OR 97220 Phone: 503-257-1600 Site Attending FAX: 503-257-1592 STUDENT HEALTH HISTORY FORM FOR OUTDOOR SCHOOL AND COMPANION PROGRAMS In order for your child to attend Outdoor School, all information on this form must be completed. If your child’s condition changes after you submit this form, please send a note to the Outdoor School nurse.
Student’s Name _____________________________Birth Date____________________ Age_____________ Sex_______________
Parent’s Name _____________________________ Home Phone_______________________ Cell Phone____________________
Parent’s Name ______________________________ Home Phone_______________________ Cell Phone____________________
Parent’s Work Phone_______________________________ Parent’s Work Phone______________________________________
Emergency Contact #2 ______________________________ Relationship_________________________ Phone_________________
____ALLERGIES (*please list below) _____ Physical Injuries (recent)
Emotional/behavioral or learning concerns
*Please provide more specific information about identified health concern including treatment needed while at Outdoor School: ___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Are there any activity restrictions i.e. strenuous hiking, tug-of-war, etc? ________________________________________________
(vegetarian option could include eggs and dairy)
Other pertinent health information:_______________________________________________________________________________
Legal parents/guardian contacted first whenever possible.
In case of medical or surgical emergency, I hereby give permission to the Outdoor School Coordinator to arrange transport for my child, as named above, to the hospital for evaluation by a physician.
Child’s Insurance Information___________________________________________________________________________________
Medication Allergy ___________________________________________________________________________________________ DO NOT SEPARATE PAGES PS11-12/PAGE 1 THIS PAGE RECORD OF MEDICATIONS ADMINISTERED BY THE OUTDOOR SCHOOL NURSE STUDENT NAME:_______________________________________________________ NURSE USE SCHOOL_____________________DATES ATTENDING_____________________
Use the following key for days medication not given: X = Not at site 0 = Student refuses/parent notified Self-administration key:SA = Self-Administration NS = No Show (Please: use one line only per dose administered) (initial each entry) ODS STOCK Medication Record (PER MD STANDING ORDERS)
(Please: use one line only per dose administered) DO NOT SEPARATE PAGES PS11-12/PAGE 4
IF YOUR CHILD IS BRINGING MEDICATION TO OUTDOOR SCHOOL PLEASE READ AND COMPLETE THE INFORMATION BELOW, IF NOT GO TO THE NEXT PAGE. MEDICATION RULES 1.
All medication must be maintained and administered by the nurse. Students are not allowed to carry their own medication. Some exceptions are made for emergency asthma inhalers and auto injectors for severe allergic reactions.
Any prescription, non-prescription medication must have the following: Parent must sign the authorization below Parent must include the following:
o Name of medication o Dose (strength and how much) of medication o Time and Dates medication should be given o Purpose or reason for medication
All medication must be in original container (prescription or over-the-counter). No medication will be accepted or given if they are sent to Outdoor School in unapproved containers (i.e., envelopes, baggies, pill planners etc.)
Prescription medication must have an accurate label. This includes samples given by physician. If the directions on the prescription label are different from what the physician is currently prescribing, written instruction is required from the physician. This also includes directions for over-the-counter medications. See “Physician Directions” below.
All inhalers must be appropriately labeled with their prescription. Sign here if you would like your child to carry and self administer his/her emergency asthma inhaler and/or auto injector.
______________________________________ (parent signature)
Name of emergency inhaler and/or auto injector and directions____________________________________________ _________________________________________________________________________________________ _ Your child must be developmentally and behaviorally able to carry and self administer his/her inhaler and/or auto injector. 3.
Vitamins/supplements cannot be given at Outdoor School without a doctor’s prescription and must be in original container. The doctor must give written permission that the student can have over-the-counter medicine with the vitamin/supplement.
PARENT/GUARDIAN AUTHORIZATION TO OUTDOOR SCHOOL NURSE TO ADMINISTER MEDICATION I am requesting that my child, ____________________________________, be given or be assisted in taking:
Parent /Guardian Signature __________________________________ Date:__________________
(This authorization applies only to the medication listed above and for the duration of treatment or week. This also authorizes an exchange of information, as necessary, between the nurse, appropriate school personnel, my child’s health provider, and/or my child’s pharmacist.)
PHYSICIAN DIRECTION (required in writing IF prescription label does not match parent direction above)
Special instructions including adverse reactions and action required:_____________________________________________ ____________________________________________________________________________________________________________ _____________________ _________________________ ______________ Physician’s Name (print or stamp) Physician’s Signature ______________________________ ___________________ ____________________ DO NOT SEPARATE PAGES PS11-12/PAGE 2 STUDENT NAME ___________________________________ AUTHORIZATION FOR ADMINISTRATION OF OVER-THE-COUNTER MEDICATION BY THE OUTDOOR SCHOOL NURSE
For the relief of minor health problems that might temporarily affect your child’s comfort while at Outdoor School, the nurse maintains a small supply of common over-the-counter medications at the site. These medications are administered, as needed, under the standing orders of the Outdoor School consulting physician(s). Your personal physician does not need to sign for the medications listed below. Donot send these medications with your student. If needed, our stock supply will be used. THE HEALTH HISTORY FORM IS CHECKED FOR ALLERGIES BEFORE ANY MEDICATION IS GIVEN. Medications available for the Outdoor School Nurse to use for your child are:
Antihistamines (Benadryl, Chlor-Trimeton)
Non-aspirin pain/fever relievers (Tylenol
*Epinephrine is a prescription medication that is kept on site for use in the event of a life threatening allergic reaction. NOTE: Brand names have been listed but their generic equivalent or the same medication of a different brand may be substituted. We do not stock chewable or liquid pain relievers. IF YOU WANT YOUR CHILD TO RECEIVE OVER-THE-COUNTER MEDICATION, IF NEEDED, AND AT THE DISCRETION OF THE OUTDOOR SCHOOL NURSE, SIGN BELOW. IF THIS LIST CONTAINS MEDICATION YOU DO NOT WANT YOUR CHILD TO RECEIVE, DRAW A LINE THROUGH THAT MEDICATION BEFORE SIGNING.
I authorize the Outdoor School Registered Nurse to administer over-the-counter medication (limited to those on list) under the direction of the consulting physician’s standing orders, as needed, to my child while at Outdoor School.
Parent / Guardian Signature _______________________________________ Date____________________ (A signature must be present above if your child needs any of the above medications while at Outdoor School).
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