MEDICINE ADMINISTRATION FORM
To Be Completed By Parent/Guardian
Race: ____________ Height: ____________ Weight: ___________ Sex:__________ Date of Birth:________________________ Social Security #______________________________ Parent:______________________________________ Street Address:_____________________________________ City:__________________________State:____________Zip:________________Phone:______________________ _____ I request that my child (named and identified above) receive medication as prescribed by our physician. _____ My child is not currently receiving prescription medication.
GENERAL MEDICATION USE PERMISSION FORM
The MSA Health Center keeps the following medications on hand. These medications will be administered only
according to your indications below. Only non-ephedrine medications will be administered. Ephedrine requires a
prescription in accordance with Mississippi law. (When available, we will stock generic brands.) All students must
report all prescription and over the counter medications to the School Nurse. The nurse or other authorized
personnel must store and administer all prescribed medications except asthma inhalers.
Do Not Use
Use Only with Parent Contact
I authorize the School Administration or Nurse to assign unlicensed school personnel who has completed the Mississippi Board of Nursing Assisted Self Administration Curriculum
the task of assisting my child in taking the above medications and any prescription medications from this date forward. I understand that additional parent/prescriber signed statements will be necessary if the dosage or type of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question arise about the medication. Medication must be registered by the school nurse. It must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and the date of drug’s expiration when appropriate.
Parent/Guardian ___________________________________ Signature _____________________________
Phone Number _____________________________________ Date ________________________________
MEDICAL EXAMINATION FORM
TO BE COMPLETED BY PHYSICIAN
Race: ____________ Height: ____________ Weight: ___________ Sex:__________ Height: ________ft. ________in. Weight: ________lbs.
Blood Pressure: ____________ Eyes: Are glasses worn?
Yes ( ) No ( ) Is color vision defective? Yes ( ) No ( )
Yes ( ) No ( ) Are drums intact? Yes ( ) No ( )
Normal ( ) Abnormal ( )
Head, Face, Neck
Normal ( ) Abnormal ( ) Vascular System
Normal ( ) Abnormal ( ) Nose and Sinuses
Normal ( ) Abnormal ( ) Abdomen
Mouth and Throat
Normal ( ) Abnormal ( ) Endocrine System
Normal ( ) Abnormal ( ) Teeth
Normal ( ) Abnormal ( )
Lungs and Chest
Normal ( ) Abnormal ( ) Neurologic
Are muscle strength and function of extremities normal and all digits present? Yes ( )
DETAILS OF ABNORMALITIES NOTED ABOVE: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ May this person, without harm to his/her health, participate in the following:
PHYSICIAN’S OPINION: Are there or have there been any physical or emotional problems that are likely to interfere with the student’s adjustment to a residential school environment or athletic activities?
If “YES”, please explain:_________________________________________________________ ______________________________________________________________________________ Please itemize all regular prescription medications on the Prescription Medicine Form. PHYSICIAN SIGNATURE: _____________________________DATE OF EXAM:_______________
Prescription Medicine Form
Note: This section must be filled out whenever a new medication is prescribed. All students
must report all prescriptions to be stored and administered through self-administration
except asthma inhalers.
Student Name _____________________________________________ Grade _________
To Be Completed by Physician (if medicine is prescribed below):
I request that my patient (named and identified above) receive the following medication while in
residence at the Mississippi School of the Arts.
Name of Medication: _________________________
Prescribed dosage and means of administration:
Time(s) to be administered: _________________________
Expected duration of treatment: ___________________
Possible side effects/adverse
reactions:______________________________________________________________ Physician’s Name ______________________Signature ____________________________
Phone Number _______________________ Date _______________________________
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