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The Country School USE FOR GRADES 341 Opening Hill Rd. Madison, CT 06443 5-8 203.421.3113 Ext. 111
Health History Update Academic Year 2010-2011
Student: _____________________________________________DOB: ____________________Grade: ________________________ Pediatrician: ____________________________________________________Phone Number: ________________________________ Medical Diagnosis/Conditions: _________________________________________________________ Allergies (food, drugs, Environmental, Animals, Insects): ________________________________________
Medication(s) taken at home: daily: ___________________________________________________________ As needed: _________________________________________________________________________
Medication necessary at school: ____________________________________________________________ Annual Medical Update:Asthma:mild moderate severe exercise-induced Inhaler needed in school: Yes No
Other Pertinent Information: _______________________________________ ___________________________________________________________________________________
Note: Please Inform the School Nurse promptly if there are any changes in the information provided on this medical form.
Consent For Medication Grades 5-8
To be administered by the school nurse up to one hour before school dismissal
ACETAMINOPHEN (Same as TYLENOL) 320-650mg orally every 4 hours.
IBUPROFEN (Same as MOTRIN or ADVIL) 1 or 2 tabs (200mg. each) orally every 6 hours.
1.General Pain/discomfort: after assessment, and up to 5 doses per school year.
2.HEADACHE: limit administration to 2 occurrences/month or 3 consecutive days
3. DENTAL PAIN: up to 4 days following dental procedure.
5. MENSTRUAL CRAMPS: limit administration to 5 days/month
If it is necessary to exceed the above limitations, an order will be required from the child’s health care provider.
I grant permission for the school nurse to administer the above dosage of medication
to my child in the event of above-mentioned symptoms while at school.
Parent/Guardian Signature: _________________________________________________________Date: ______/______/20___
I request that NO medication be administered to my child
while at school.
Parent/Guardian Signature: __________________________Date: _______
Consent For Overnight Field Trip Medication
PAIN: Headache, Muscle, Menstrual, and Dental. FEVER: >101F
Acetaminophen (Tylenol Brand) 325-650mg orally every 4 hours
Ibuprofen (Advil. Motrin, brand) 200mg-400mg orally every 6 hours
MOTION SICKNESS: Benadryl 25 mg capsule (1 capsule) orally every 4-6 hours
ALLERGIC REACTION: Benadryl 50 mg (tablets-25 mg OR 4tsp-12.5mg/tsp) orally every 6-8 hr.
DIARRHEA: Imodium 2mg-4mg not to exceed 16mg/day.
INDIGESTION: Tums 750mg as symptoms occur.
I grant permission for my child to receive the above dosage of medication administered by a school
faculty member in the event of above-mentioned symptoms while on an overnight field trip.
Parent/Guardian Signature: ______________________________________________________________ Date: ____/______/20_____
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