Microsoft word - 2013 student medical form

STUDENT HEALTH HISTORY &
RECOMMENDATIONS BY LICENSED MEDICAL PERSONNEL
INSTRUCTIONS
FORM 1 (A&B) – to be completed by parent/guardian Complete Form 1
Attach a copy of student’s medical insurance card
Sign form
Please provide student’s legal name on medical form (no nicknames please)
Make a copy and bring the duplicate to campus on registration day
Mail original to SIG office no later than May 15
FORM 2 (A&B) – to be completed by medical personnel Provide FORM 1 to your child’s healthcare provider for review, completion, and signatures. Parent/guardian should sign where indicated if applicable. Please note that physicals must have been given after June 1, 2011. Copies of immunization forms from health-care providers or state or local government are acceptable. All medication that will be brought to campus must be listed on form 2B
Mail to SIG office no later than May 15
Make a copy of ALL medical forms and bring the duplicate copy to campus on registration day Only medication listed on form 2B, in its original container, and written in English will be accepted and administered during the program. If your child has one of the following conditions, please log in to the SIG student portal at www.giftedstudy.org, download and have your pediatrician complete the applicable action plan Allergies (requiring medications such as epi-pens and inhalers) Asthma Diabetes Seizures
Please submit all medical forms (including action plans) no later than May 15 one of the following
ways:
Mail:
Summer Institute for the Gifted
River Plaza
9 West Broad Street
Stamford, CT 06902

E-mail: [email protected]
Fax: 203-399-5201


Have a question, please call: (866) 303-4744
STUDENT HEALTH
Summer Institute for the Gifted
9 West Broad Street
Stamford, CT 06902
(866) 303 – 4744
Fax: 203-399-5201
[email protected]
This page to be completed by parent/guardian
SIG Campus SIG Student ID#

Parent/guardian name
2nd Parent/guardian name
Emergency contact #1 name (other than parent)
Emergency contact #2 name (other than parent)
Allergies:
No known allergies This student is allergic to: The environment (insect stings, hay fever, etc.) Requires Epi-Pen (Please describe below what the student is allergic to and the reaction seen.)
Diet, Nutrition:
Restrictions of Program and Activities:
My child can participate without restrictions. My child can participate with the following restrictions or adaptations. (Please describe) Medical Insurance Information: This student is covered by family medical/hospital insurance
Health Care Providers:
Please attach a copy of
Please attach a copy of
the back of student’s
the front of student’s
health insurance card
health insurance card
STUDENT HEALTH

Student Name
SIG Campus
SIG Student ID #
This page to be completed by parent/guardian
General Health History: Check “Yes” or “No” for each statement. Explain “Yes” answers below.
Has/does the student:
1. Ever been hospitalized? Yes
12. Passed out/had chest pain during exercise? 3. Have recurrent/chronic illnesses? Yes 13. Had mononucleosis during the past 12 months? 14. If female, have problems with menstruation? 15. Have problems with falling asleep/sleepwalking? Yes 6. Had asthma/wheezing/shortness of breath? Yes 18. Have problems with diarrhea/constipation? 10. Wear glasses, contacts, or protective eyewear? Yes Please explain “Yes” answers in the space below, noting the number of the questions. Mental, Emotional, and Social Health Check “Yes” or “No” for each statement. Has the student:
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD) 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? 3. During the past 12 months, seen a professional to address mental/emotional health concerns? 4. Had a significant life event that continues to affect the student’s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc.)
Please explain “Yes” answers in the space below, note the number of the question. The program may contact you for additional
information.
What have we forgotten to ask? Please provide in the space below any additional information about the student’s health that you
think important or that may affect the student’s ability to fully participate in the program. Attach additional information as needed.
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the student to whom it pertains. The person described has
permission to participate in all program activities except as noted by me and/or an examining physician. I give permission to the
physician selected by the program to order x-rays, routine tests, and treatment related to the health of my child for both routine health
care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure
proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on
a “need to know” basis with program staff. I give permission to photocopy this form. In addition, the program has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my
child’s health status. I understand that it is my responsibility to pick up any medication at the end of the program. If I do not pick up the
medication I understand the medications will be destroyed 7 days following the last day of the program.
Signature of parent/guardian___________________________________ Date________________________________
If for religious reasons or other reasons you cannot sign this agreement, please contact the program for a legal waiver which must be signed for
attendance.
STUDENT HEALTH CARE
RECOMMENDATIONS BY LICENSED
Summer Institute for the Gifted
9 West Broad Street
MEDICAL PERSONNEL
Stamford, CT 06902
(866) 303 – 4744
Fax: 203-399-5201
[email protected]
This section to be completed by medical personnel
SIG Campus SIG Student ID
Please note that physicals must be performed after June 1, 2011
(legal) First Name
Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations are required. Copies
of immunization forms from health-care providers or state or local government are acceptable; please attach to this form.
If student has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Parent/Guardian Signature ____________________________________ Date_______________________ Physical exam done today: Note: Students last physical must be after June 1 of prior year. Allergies:
To the environment (insect stings, hay fever, etc. – list) Describe previous reactions: Diet, Nutrition: Has a medically prescribed meal plan or dietary restrictions (describe below) The student is undergoing treatment at this time for the following conditions: Other treatment/therapies to be continued at the program: Do you feel that the student will require limitation or restrictions to activity while attending the program? If you answered “Yes” to the question above, what do you recommend? (describe below or attach additional information as needed) STUDENT HEALTH CARE
RECOMMENDATIONS BY LICENSED MEDICAL Student Name
SIG Campus
PERSONNEL
SIG Student ID #
This section to be completed medical personnel and signed by both medical personnel and parent/guardian.
Medication: Any medication sent to camp must be documented in this area
This student will not take any medications (including over-the-counter) while attending the program. This student will take the following medication(s) while at the program. “Medication” is defined as any substance a person takes to maintain and/or improve their health. This includes vitamins, dietary
supplements, and natural remedies. Please list all medications the student will take daily or as needed while attending the summer
program. No medication will be administered or accepted on campus until all information below is completed and signed by a parent
and medical professional. Prescriptions are to be written in English, in the original pharmacy container with labels which show the
participant’s name and how the medication should be given. Provide enough medication to last the student the duration of the program.
Medication name
Medication name
Medication name
Non-Prescription Medication
The non-prescription medication (or its generic equivalent) listed below may be stocked in the infirmary and are used on an as needed
basis to manage illness and injury. Please check off those medications that the student may NOT receive:
“I have discussed the program with the student’s parent/guardian. It is my opinion the student is physically and emotionally
fit to participate in an active program (except as noted).
Name of licensed provider (please print): __________________________________ Office Address__________________________________________________________Phone________________________________ Physician Signature____________________________________ Date___________________________________________

Source: http://www.giftedstudy.org/pdf/form_medical.pdf