Personal Information Form Medical History/Prophylaxis Information First Name, Last Name
/ / Age: / / Age:Age: Yes No Yes No Yes No Yes No
(Accutane) or Acitretin (Soriatane)? Taking Theophylline
For additional family members or other persons, please turn page over. Do Not Write Below this Box Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin Doxycycline Doxycycline Doxycycline Doxycycline Amoxicillin Amoxicillin Amoxicillin Amoxicillin Pediatric Med Pediatric Med & Pediatric Med & Pediatric Med &Dosage &Dosage Administered by:____________________Date:______________Location/Site__________________ Personal Information Form (cont.) First Name, Last Name Yes No Yes No Yes No Yes No
or Acitretin (Soriatane)? Taking Theophylline
For additional family members or other persons, please select another Do Not Write Below this Box Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin Doxycycline Doxycycline Doxycycline Doxycycline Amoxicillin Amoxicillin Amoxicillin Amoxicillin Pediatric Med Pediatric Med Pediatric Med & Pediatric Med & &Dosage & Dosage Administered by:____________________Date:______________Location/Site_________________2 /2006 HISTORIAL MEDICO/FORMA DE PROFILAXIS Historial Medico/Información de Profilaxis Apellido
Escriba peso si es menor de 100 Peso: Peso:
Si No Si No Si No Si No
convulsiones o epilepsia? ¿Toma Warfarin (Coumadin)?
Acitretin (Soriatane)? ¿Toma Theophylline
Para miembros de la familia adicionales u otras personas, por favor seleccione otra forma No Escriba Debajo de estos Cuadros Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin Doxycycline Doxycycline Doxycycline Doxycycline Amoxicillin Amoxicillin Amoxicillin Amoxicillin Med yDosis Med yDosis Med yDosis Med yDosis Pediátrica Pediátrica Pediátrica Pediátrica Administrada por:_________________Fecha:______________Ubicacion/Lugar_________________ HISTORIAL MEDICO/FORMA DE PROFILAXIS Apellido: Historial Medico/Información de Profilaxis Apellido
Escriba peso si es menor de 100 Peso: Peso:
Si No Si No Si No Si No
convulsiones o epilepsia? ¿Toma Warfarin (Coumadin)?
Acitretin (Soriatane)? ¿Toma Theophylline
Para miembros de la familia adicionales u otras personas, por favor seleccione otra forma No Escriba Debajo de estos Cuadros Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin Doxycycline Doxycycline Doxycycline Doxycycline Amoxicillin Amoxicillin Amoxicillin Amoxicillin Med yDosis Med yDosis Med yDosis Med yDosis Pediátrica Pediátrica Pediátrica Pediátrica Administrada por:_________________Fecha:______________Ubicacion/Lugar_________________ 2/2006
Self Medication Order for Benadryl Only The administration of medication to a child during the before and after school SACC Program will be permitted only when the child’s physician certifies in writing that the administration of medication during the before and after school SACC Program is essential to the health of the child and may be self-administered by the child safely. The parent/g
L'EBRAISMO NELLA CULTURA OCCIDENTALE La Bibbia non è un libro su Dio, ma un libro sull'uomo. Chi è l'uomo nella Bibbia? Un essere postonel travaglio, ma che ha i sogni di Dio: il sogno di un'umanità che sia veramente la Sua immagine,che rispetti la saggezza, la giustizia e la misericordia; il sogno di Dio di non essere mai solo , ma diavere un egnere umano a compagno nel dramma continuo de