A L B U Q U E R Q U E A C A D E M Y MEDICAL FORM INSTRUCTION SHEET School Year

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1 MEDICAL FORM INSTRUCTION SHEET PLEASE READ CAREFULLY BEFORE COMPLETING FORMS Your child s health and safety are as important to us as to you. Each year, following state and New Mexico Activities Association guidelines, we require physical examinations for all students. Participation in all our programs including experiential and physical education, interscholastic and intramural athletics, and other school activities depends upon completion of the medical forms. Please make an appointment with your health care provider as soon as possible after receiving this packet. Most health care providers require at least four weeks of scheduling time for physical exams. The information contained within these forms will help us to provide more appropriate responses to your child's needs and will be shared only with members of our faculty and staff working with your child. If this physical examination requirement creates a financial hardship for your family, please call the school nurse, Jen Duvall, at Please return the following forms by July 15 th (for students returning to 8 th through 12 th grades, class schedules will be held until all forms are received or arrangements have been made with the school nurse): Emergency Information Form This form must be completed and signed by the parent/guardian. Please mark any item N/A if it is not applicable to your child. List phone numbers (work, cellular, or pager) in order by which you would first prefer to be contacted in case of an emergency. For alternative emergency contacts, please select someone who is familiar with your child and within the Albuquerque area, if possible. Indicate your child s insurance carrier. All students participating in athletics must have private insurance or purchase accident insurance through Albuquerque Academy. Information on accident insurance was included in your enrollment contract package. For further information on Albuquerque Academy Accident Insurance, contact the Albuquerque Academy Business Office at Please inform the school nurse of any changes in your child s health, health care provider, or insurance carrier during the school year. Consent for Over-the-Counter Medication Administration This form is to be completed if you would like your child to receive any over-the-counter medications from the school nurse for illnesses or injuries while at school. Students may carry and self-administer only a single dose per day of any over-the-counter medications. Any over-the-counter medication carried by a student must be kept in the original manufacturer s container. Medication Administration Form This form must be completed if your child will be taking or carrying any type of prescribed medications (i.e., Albuterol, Imitrex, Epi-Pens) longer than ten consecutive days on the Albuquerque Academy campus during the school year. For students using asthma medication at school, please sign and have your healthcare provider complete the Asthma Action Plan on the backside of the Medication Authorization Form. Students who take any type of controlled substance (e.g., Ritalin/Dexedrine) during school hours will not be allowed to carry or self-administer their medication. Arrangements must be made with the school nurse for medication administration. This form must be completed and signed by the parent/guardian and your health care provider if your child will be taking prescribed medication at school daily. If your child will be taking any prescription medications at school for ten days or less at any time during the school year, please contact the school nurse, Jen Duvall, at Medical History and Physical Evaluation Form The Medical History section of this form is to be completed by the parent/guardian. The Physical Evaluation section of this form is to be completed by your health care provider. This form must be signed by your health care provider, a parent/guardian, and the student. The physical examination must be performed after April 1 st (a New Mexico Activities Association requirement). We are required by law to maintain records of students previous immunizations. All immunizations must be up to date. Please provide copies of official documentation for any updates in your child's immunization record. If this is your child s first year at Albuquerque Academy, official documentation of all immunizations must be submitted with this form. Your child will not be allowed to attend school without immunization records. No student may attend classes, start practice, or travel on school trips until all forms are fully completed and returned to the school. Thank you for attending to this essential task.

2 STUDENT EMERGENCY INFORMATION FOR HEALTH ROOM, EXPERIENTIAL EDUCATION, FIELD TRIPS, INTERSCHOLASTIC ATHLETICS This form must be completed in its entirety for every student. Grade Entering Student s Name Date of Birth (Last) (First) (Middle) Address Student s Cell# (Street) (City) (Zip Code) Parent/Guardian Home Phone 1 st Contact # 2 nd Contact # Parent/Guardian Home Phone 1 st Contact # 2 nd Contact # My child has the following health conditions (e.g., diabetes, asthma, kidney problems, seizures, heart problems, etc.): My child has the following athletic injury or orthopedic condition: Activity restrictions due to the above conditions: My child has these allergies (medication, food, environmental [insect bites, pollen, latex]): Severity of allergy (e.g., mild, moderate, anaphylactic) Previous hospitalization due to an allergic reaction: YES NO My child has these dietary restrictions: My child is now taking the following medication(s): (attach dosage instructions) My child may take nonprescription pain medication administered outside of school nurse s office (e.g., Tylenol [acetaminophen] or Advil [ibuprofen]): YES NO Indicate Preference Date of last Tetanus Booster Please list your Albuquerque hospital preference: Should questions arise regarding my child s participation in or care during an activity, and parents/guardians are not available, please consult with: 1. Name Home Phone Relationship to my child Work/Cellular/Pager / / 2. Name Home Phone Relationship to my child Work/Cellular/Pager / / Health Care Provider Phone Dentist Phone PARENTAL CONSENT: I/We hereby give my consent for to participate in interscholastic athletics and other school-sponsored or related activities at Albuquerque Academy and authorize Albuquerque Academy to provide the information as required on this form to the New Mexico Activities Association. The financial responsibility for securing care of injuries incurred while participating in school-sponsored activities is a matter between the parent(s)/guardian(s) and the health care provider. Albuquerque Academy may not pay doctors, dentists, or hospitals for any treatment of any child. RELEASE OF MEDICAL INFORMATION: I/We authorize the release of any information contained on this form to faculty, staff, or volunteer members at Albuquerque Academy that may be working with my/our child. INSURANCE: Albuquerque Academy requires that all students involved in athletics must be insured. -I/We have applied for student accident insurance through Albuquerque Academy. YES NO (Please check one) -I/We have accident insurance with another carrier: Insurance Co. Policy # Phone: Insurance Co. Address: Policy Holder s Name: AUTHORIZATION FOR MEDICAL SERVICES: I/We request that I/we be contacted within a reasonable time in the event of illness or injury requiring medical services. In the event I/we cannot be reached, I/we parent(s)/guardian(s), hereby designate Experiential Education Faculty, School Nurse, Emergency Response Team, Athletic Director, Team Coach, Athletic Trainer, authorized chaperone or his/her designee to act in my/our behalf to authorize such hospitalization, medical attention and surgery as may be required in an emergency because of illness or injuries sustained by my/our child/ward while participating in school-sponsored activities. In the event I/we cannot be reached and the situation calls for medical attention, I/we recognize and relinquish our responsibility to a practicing physician and/or medical personnel acting in the best interest of my/our child/ward. I/We hereby assume financial responsibility for hospitalization, medical attention, emergency transportation and surgery provided. (Parent/Guardian Signature) (Date)

3 CONSENT FOR OVER-THE-COUNTER MEDICATION ADMINISTRATION The Albuquerque Academy Health Center has the following over-the-counter medications available as indicated below, which can be administered to your child for the treatment of acute illnesses or minor injuries. In order for these medications to be administered, it will be necessary for you to complete the following information. If you do not wish for your child to receive any of these medications, or would like to be contacted before the medication is given, please indicate what your preference is by checking the boxes below. For students with temperatures higher than 100 F, parents will be contacted and the student will be sent home. Students will not receive more than one dose of a specific medication per day nor will any medication be administered more than three consecutive days unless other arrangements have been made with the school nurse. If symptoms persist, parents will be consulted regarding follow-up care with their health care provider. Student s Name: Date of Birth Parent/Guardian s Name: Daytime Phone Number Medical Conditions or Medical Treatments of Student: Allergies (food, drug, environmental): DO NOT GIVE DRUG CALL BEFORE ADMINISTERING YES NO Antacid/Antigas (calcium carbonate 675 mg; magnesium hydroxide 135 mg; simethicone 60 mg) given for acid indigestion, heartburn Advil (ibuprofen) 200 to 400 mg given for muscle aches, menstrual cramps, headaches, joint pain, fever, sore throat, or ear ache Tylenol (acetaminophen) 325 to 650 mg given for muscle aches, menstrual cramps, headaches, joint pain, fever, sore throat, or ear ache Benadryl (diphenhydramine) 12.5 to 25 mg given for mild to moderate allergic reactions such as rash, hives, runny nose, bug bites Claritin (loratadine) 10 mg given for mild to moderate allergic reactions such as rash, hives, runny nose (only one dose per 24 hour period given) Decongestant (pseudoephedrine 30 mg; phenylephrine 10 mg) given for sinus congestion Cough Drops (contains Menthol) given as an oral pain reliever/cough suppressant Benadryl Cream topical application of 2% diphenhydramine to be applied to local skin reactions (rashes, bug bites) Hydrocortisone Cream topical application of 1% hydrocortisone to be applied to local skin reactions (rashes, bug bites) Arnica Gel herbal medication applied topically to minor joint injuries and bruises or contusions The Albuquerque Academy Health Center has my permission to administer the above medications (unless indicated above) to my child when necessary. Medications will not be administered without parental/guardian signature. Parent/Guardian Signature Date

4 HEALTH CARE PROVIDER S MEDICATION ORDER AND AUTHORIZATION FORM For medication to be safely administered during school hours on the Albuquerque Academy campus please complete every item on this form. Please fill out a separate authorization form for each medication. If you have any questions, please call Jen Duvall, School Nurse, at FOR PRESCRIBED ASTHMA MEDICATION ONLY, PLEASE COMPLETE THE ASTHMA ACTION PLAN ON THE REVERSE SIDE OF FORM. STUDENT S NAME: DATE OF BIRTH Please Print Last First HEALTH CARE PROVIDER S ORDER AND STUDENT COMPETENCY STATEMENT: 1. I have examined this student for (diagnosis) and have determined that he/she requires medication during school hours. 2. Name of medication: Dosage: 3. Time of administration: Duration of administration (how long?): 4. Please check this box if this medication is to be administered only when a morning dose of medication is forgotten at home (it is the parents responsibility to contact school nurse and request medication be given). 5. Special instructions regarding this medication: 6. Contact me if the following signs or symptoms appear: I believe this student is able to carry and administer her/his own medication (excluding controlled substances) at the appropriate time and in the appropriate way. Please check: YES NO Health Care Provider Signature: Date: Health Care Provider Name (print): Phone: PARENT/GUARDIAN STATEMENT please complete the appropriate statement below: 1. I/We, the undersigned parent(s)/guardian(s) of, believe he/she is competent to carry and administer his/her own medication (excluding controlled substances) at the appropriate time and in the appropriate way. I/We give my/our permission for him/her to do so. I/We agree that my/our child will carry the medication in a pharmacy labeled container with only the amount of medication required for the day. 2. I/We, the undersigned parent(s)/guardian(s) of, request that either the school nurse or a designated school employee administer the above medication according to the health care provider s instructions. I/We agree to furnish the necessary prescribed medicine in the properly labeled container, to provide replacement medication as necessary, and I/we agree to notify the school nurse immediately if the health care provider or medication prescription is changed. Parent/Guardian Signature: Date: Home Phone: Work Phone:

5 NEW MEXICO ASTHMA ACTION PLAN FOR SCHOOLS School District Date School Name School Nurse / Health Asst. School Phone # / FAX # / PARENT/GUARDIAN: Please complete the information in the top sections and sign consent at bottom of the page. Student Name Date of Birth Student # *Health Care Provider Name/Title Provider s Office Phone / FAX # Parent/Guardian Parent s Phone #s Emergency Contact Contact Phone #s Allergies to Medications: Asthma Triggers Identified (Things that make your asthma worse): Date of student s Date of Last Inhaler is kept: Exercise Colds Smoke (tobacco, fires, incense) Pollen Dust last visit to medical Flu Shot With Student Strong Odors Mold/moisture Stress/Emotions Pests (rodents, cockroaches) provider: In Classroom Gastroesophogeal reflux Season: Fall, Winter, Spring, Summer Health Office Animals Other (food allergies): / / / / Other HEALTH CARE PROVIDER: Please complete Severity Level, Zone Information and Medical Order Below Asthma Severity: Intermittent or Persistent: Mild Moderate Severe Green Zone: Go! Take Control Medications EVERY DAY You have ALL of these: Breathing is easy No cough or wheeze Can work and play No symptoms at night Peak flow (optional): Greater than (More than 80% of Personal Best) Personal best peak flow: No controller medication is prescribed. Always rinse mouth after using your daily inhaled medication., puff(s) MDI with spacer times a day Inhaled corticosteroid or inhaled corticosteroid/long-acting -agonist, nebulizer treatment(s) times a day Inhaled corticosteroid, take by mouth once daily at bedtime Leukotriene antagonist For asthma with exercise, ADD:, puff(s) MDI with spacer 5 to 15 minutes before exercise For nasal/environmental allergy, ADD: Yellow Zone: Caution! Continue CONTROL Medicine & ADD RESCUE Medicines- You have ANY of these: DO NOT LEAVE STUDENT ALONE! Call Parent/Guardian when rescue medication is given. Cough or mild wheeze, puff(s) MDI with spacer & every hours as needed Tight chest Fast-acting inhaled -agonist First signs of a cold OR Problems sleeping,, nebulizer treatment(s) & every hours as needed Playing or working Fast-acting inhaled -agonist Peak flow (optional): Other to Call your MEDICAL PROVIDER if you have these signs more than two times a week, or if your rescue (50% - 80% of Personal Best) medicine does not work! If symptoms are NOT better OR peak flow is NOT improved, go to RED ZONE Red Zone: EMERGENCY! Continue CONTROL Medicine & ADD RESCUE Medicines and GET HELP! You have ANY of these: DO NOT LEAVE STUDENT ALONE! Call for emergency 911 and start treatment Cannot talk, eat, or walk well, puff(s) MDI with spacer & every 20 minutes until paramedics arrive Medicine is not helping or Getting worse, not better Breathing hard & fast Blue lips & fingernails Peak flow (optional): Less than (Less than 50% of Personal Best) HEALTH CARE PROVIDER ORDER AND SCHOOL MEDICATION CONSENT Check all that apply: Student has been instructed in the proper use of his/her asthma medications and IS ABLE TO CARRY AND SELF-ADMINISTER his/her INHALER AT SCHOOL. Student is to notify designated school health personnel after using inhaler at school. Student needs supervision or assistance when using inhaler. Student is unable to carry his/her inhaler while at school. GREEN means Go! Use CONTROL medicine daily YELLOW means Caution! Add Rescue medicine RED means EMERGENCY! Get help from a provider now! Fast-acting inhaled -agonist OR, nebulizer treatment(s) every 20 minutes until paramedics arrive Fast-acting inhaled -agonist Call 911 and start treatment immediately. Then call Parent/Guardian. Use only if Oxygen and Pulse Oximeter available: Administer Oxygen l/min for 02 Sat. % and measure 02 Sat. every minutes Parent/Guardian: I approve of this asthma action plan. I give my permission for the school nurse and trained school personnel to follow this plan, administer medication(s), and contact my provider, if necessary. I assume full responsibility for providing the school with the prescribed medications and delivery and monitoring devices. I give my permission for the school to share the above information with school staff that need to know and permission for my child to participate in any asthma educational learning opportunities at school. SIGNATURE: DATE: *SIGNATURE/TITLE DATE SCHOOL NURSE: DATE: IHP/EAP NANDA NIC-Periodically Assess the Effectiveness of the AAP and Asthma Education NOC- Patent Airway NMCOA - New Mexico Council on Asthma September 2012

6 Date of Exam Name A L B U Q U E R Q U E A C A D E M Y PART A: Health History Form This section must be completed prior to visiting your health care provider Sex Age Grade School Sport(s) Date of birth Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects Explain Yes answers below. Circle questions you don t know the answers to. GENERAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections 3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU Yes No 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 7. Does your heart ever race or skip beats (irregular beats) during 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure A heart murmur High cholesterol A heart infection Kawasaki disease Other: 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 10. Do you get lightheaded or feel more short of breath than expected during exercise? 11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath more quickly than your friends during exercise? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant 14. death Does anyone syndrome)? in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic 15. ventricular Does anyone tachycardia? in your family have a heart problem, pacemaker, or implanted defibrillator? 16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? BONE AND JOINT QUESTIONS Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or 20. crutches? Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome 22. or Do dwarfism) you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS Yes No 26. Do you cough, wheeze, or have difficulty breathing during or after exercise? 27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle 30. (males), Do you have your groin spleen, pain or any or a other painful organ? bulge or hernia in the groin area? 31. Have you had infectious mononucleosis (mono) within the last month? 32. Do you have any rashes, pressure sores, or other skin problems? 33. Have you had a herpes or MRSA skin infection? 34. Have you ever had a head injury or concussion? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 36. Do you have a history of seizure disorder? 37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms 39. or Have legs you after ever being been hit unable or falling? to move your arms or legs after being hit or falling? 40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising? 42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision? 44. Have you had any eye injuries? 45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to or has anyone recommended that you gain or lose weight? 49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 52. Have you ever had a menstrual period? 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain yes answers here

7 PART B: Student Physical Evaluation THIS SECTION OF THE FORM IS TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER Name Date of Birth Date of Exam EXAMINATION Height : Weight : BMI %ile: Male Female BP( / ) B/P %ile: Pulse: Vision R 20/ L 20/ Corrected Y N MEDICAL NORMAL ABNORMAL FINDINGS Appearance Marfan stigmata (kyphoscoliosis, high-arched, palate, pectus excavatum, arachnodactyly, arm span>height, hyperlaxity, myopia, MVP, arotic insufficiency) Eyes/ears/nose/throat Lymph nodes Heart a Pulses Pupils equal Hearing Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI) Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only)b Skin HSV, lesions suggestive of MRSA, tinea corporis Neurologic c MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck-walk, single leg hop aconsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. bconsider GU exam if in private setting. Having third party present is recommended. cconsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. Samples of Classification of sports by contact: Contact Contact/Collision: Football Soccer Wrestling Limited Contact: Baseball/Softball Basketball Diving Volleyball Field: High Jump, Pole Vault Non-Contact Strenuous: Dance Field: Discus, Javelin, Shot-put Running, swimming, weight lifting Tennis Experiential Education: Hiking, rock climbing, canoeing, Backpacking, snowshoeing, ropes course Non-strenuous: Golf, bowling

8 PART C: Health Care Provider s Statement and Parental Release Statement THIS PAGE MUST BE SIGNED BY YOUR HEALTH CARE PROVIDER, A PARENT/GUARDIAN, AND THE STUDENT HEALTH CARE PROVIDER S STATEMENT I certify that I have, on this date, reviewed the history and examined this student and that on the basis of the examination requested by the school authorities and the student s medical history as furnished to me, it is permissible for this student to participate as indicated below. I have also discussed any questions the parent(s)/guardian(s) and student may have regarding participation in interscholastic activities. 1. Cleared for all classifications Cleared after completing evaluation/rehabilitation for: NOT cleared for: Contact Sports: Contact/Collision Limited Contact Non-Contact Sports: Strenuous Non-Strenuous 2. Immunizations are current (Please attach a copy of the immunization record if the student is new to Albuquerque Academy or if any additional immunizations have been given. See the back of this form for a copy of the returning student's current immunization record.) Health Care Provider Name (Please Print) Health Care Provider Signature Date Health Care Provider Address Phone ACKNOWLEDGMENT OF INJURY RISKS, MATURITY STATEMENT FOR CONTACT SPORTS, AND PERSONAL MEDICATION NOTIFICATION 1. I/We, the parent(s)/guardian(s) and the student, are aware that preparation for and participation in interscholastic athletics involves many risks of serious and permanent injury to the student-athlete. We understand and acknowledge the danger of these severe injuries as inherent in any physical activity that may involve vigorous physical contact. We also understand that the likelihood of injury increases in contact sports in those students who are not of a comparable physical maturity level with other participants. We have discussed any concerns we may have about our child s maturity level with our health care provider. 2. I/We, the parent(s)/guardian(s) and the student, hereby state that the medical history has been reviewed and that the questions are accurate to the best of our knowledge. We have also completely read, understand, and agree to all of the above mentioned statements and their content. 3. I/We, the parent(s)/guardian(s) give permission for any information contained within this form to be shared with faculty or staff members of Albuquerque Academy working with my/our child. Student Signature Date Parent/Guardian Signature Date

9 PART D: Immunization History IMMUNIZATION HISTORY FOR Health Facility Jen Duvall, CFNP, RN, MSN, MPH (505) (505) fax Wyoming Blvd NE Albuquerque, NM 87109