Health Information - Fairfax County Public Schools

1 SS/SE-71 (5/21) Health INFORMATIONC omplete this form annually to inform us about your student's Health conditionthat affects his or her school dayName of emergency medication:(OVER)This form is necessary to inform the Public Health Nurse (PHN) of your child's Health status and to plan for Health needs that may impact his/her school day. Information is only shared with required school staff as needed. Information provided on this form is protected by the Family Educational Rights and Privacy Act (FERPA) as part of the student's educational record and is securely stored in the Health room.

2 For any changes to your student's Health condition during the school year or questions regarding this form, please contact the PHN through the Health room at your child's A: Demographics:Student Name: LastFoods:Insect Sting:LatexConditionCheck if YesSevere Allergies/AnaphylaxisAsthmaDiabetesSeizu resCommentSection C: Current Physical Health Conditions:Section B: Severe or Life-Threatening Health Conditions:Epinephrine prescribed?Epinephrine injection previously given?YesNoYesNoTriggers:Inhaler prescribed?Number of Emergency Room (ER) Visits in the last calendar year:Type 1 Type 2 Glucose Monitoring:Type of Seizure:Emergency Medication Needed at school ?

3 YesNoCheck if YesBlood DisorderAllergies (non-life threatening)CancerCystic FibrosisDental/Oral Health ConditionEar, Nose & Throat ConditionsEndocrine DisorderFood IntoleranceFood/Dietary PreferenceGastrointestinal/Stomach/Bowel Hearing ConditionsHeart/CardiovascularKidney/Uri nary Tract DisordersHeadache/MigrainesLung Disease (other than Asthma)Mobility Impairment(other than Diabetes)FirstMiddleDate of BirthSchool YearSchool NameGradeTeacher/CounselorGender:Parent/ Legal Guardian NameParent/Legal Guardian NameMaleFemaleWork Phone NumberWork Phone NumberCell Phone NumberCell Phone NumberHome Phone NumberHome Phone NumberIf yes, date of injection:ExerciseEnvironmentalUpper Respiratory InfectionOther:Nebulizer Treatment prescribed?

4 YesYesNoNoDiagnosis Date:GlucometerCGMS yringePenPumpInsulin Administration:NoYesVNS implanted?Date of last seizure:ConditionComment (Please provide details)Gastrointestinal/Digestive DistressYesNoCurrently ImmunocompromisedYesNoFoods:Non BinarySS/SE-71 (5/21) Health INFORMATIONC omplete this form annually to inform us about your student's Health conditionthat affects his or her school dayLast NameFirst NameDate of BirthSection D: Current Health Conditions, Continued:ConditionCheck if YesCommentEmotional/Mental Health Conditions:Section E: Health Procedures.

5 If your child has a Health condition, does your child require any Health procedures or need any special equipment during the school days?YesNoIf you answered Yes, please describe:Section F: List all medications and dosages your child receives on a regular basis and indicate which ones to be taken at school :Parent or guardian is responsible for providing the school with any medication, special food, equipment that the student may require during the day. Medication, Procedure Authorization, and Physical Education (PE) forms may be found at or obtained in the school Health Consent.

6 I agree to allow my child's healthcare provider(s) to discuss Information contained in this form with FCPS staff and YesNoHealthcare Provider NameHealthcare Provider Phone NumberParent/Guardian Name (Print or Type)Parent/Guardian SignatureDatePublic Health Nurse Use Only Below This LineHIF ReviewedFollow Protocol (SH Care Care Guidelines) Health Condition List (Medical Flag)Action Plan/ Health Plan or ProcedurePublic Health Nurse NamePublic Health Nurse SignatureDatePublic Health :Muscle/Bone/Joint/ArthritisNeurological (other than seizures)Skin ConditionVision ConditionsOther Health ConditionsADD/ADHDA nxietyDepressionEating DisorderOther:Provider DiagnosedUnder TreatmentProvider DiagnosedProvider DiagnosedProvider DiagnosedProvider DiagnosedUnder TreatmentUnder TreatmentUnder TreatmentUnder TreatmentYesNoYesNoYesYesYesYesYesYesYes YesNoNoNoNoNoNoNoNoBrain Injury/Concussion/Date Diagnosed:Cerebral PalsyOther:EczemaOther:Contacts/GlassesN on-CorrectableOther:AutismDown's SyndromeOther.