Lexington Prep School Medical Form

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Transcription:

Lexington Prep School Medical Form Student Name Gender ( M / F ) Date of Birth Parent/Guardian Name_ Relationship Email_ Parent/Guardian Name_ Relationship Email_ Physician Name_ Phone_ Will your child be taking medication? Yes No If yes, please complete attached prescription form Does the student have any allergies or medical issues that we need to know about and/or could limit school activities? Yes No If yes, please explain: The medical information provided above accurately represents the student. I give my permission for my son/ daughter to participate in any school activities except as noted above. I hereby give permission to the nurse/ physician selected by LPS to provide treatment for the health of my child. In the event of an emergency in which, I or my emergency contacts cannot be reached, I hereby give permission to the physician selected by LPS to hospitalize and/or secure proper treatment for the student named above. Signature of parent or guardian Date Updated September 2018

Dear Parents/Guardians, As your students prepares to come to Lexington Prep School, we want to make you aware of the following health requirements: A physical exam, in English, performed within 24 months of the student s start date. Exam must include physician s name, address and phone number. MA School Health Record form attached for reference and usage (if necessary) Immunization Records (in English) Massachusetts State Law Requires that all student provide written proof of the following immunizations: 4 doses of diphtheria, tetanus and pertussis (DTP) 4 doses of polio 2 doses of measles, mumps and rubella (MMR 3 doses of hepatitis B 2 doses of varicella vaccine or documentation of chickenpox disease in childhood, signed by the physician. 1 dose of Tdap vaccine 1 dose of Meningococcal (MCV4/Menactra or MenACWY) o We have a separate waiver available to sign if your student can not have the meningococcal vaccination. See attached documentation. TB please have your medical provider fill out the attached Pediatric TB Risk Assessment Form. We also ask that you sign and return to us the Permission to Medicate/Administer Medication form. We provide 24 hour nursing care to all the students while attending the LPS programs, and should your student require certain medication for minor ailments, we ask your general permission on that form. Health Insurance is required for all students while attending Lexington Prep School courses. Please provide proof of health insurance. Sincerely, Lexington Prep School Nursing Staff

Permission to Medicate/Administer Medication I give the school nurse permission to administer the following medications to (student name) on an as needed basis. (Check all that apply) Acetaminophen Tylenol (for pain and/or fever) Ibuprofen Advil/Motrin (for pain and/or fever) Antacid Tums (for stomach aches and indigestion) Bismuth subsalicylate Pepto Bismol (for nausea, vomiting and diarrhea) Antibiotic Ointment Neosporin/Bacitracin (for cuts and scrapes) Calamine Lotion Calamine/Caladryl (for insect bites, poison ivy, skin irritation) Eye Drops Visine (for redness and irritation) Hydrocortisone cream Hydrocortisone 1% anti itch cream Diphenhydramine HCL Benadryl (for allergy and itch) Current medications child takes including drug name, dosage, route, time(s) of day and if taken with food. Are these medication(s) to be administered at school? Yes No Medication 1: _Taken with food? Yes No Dosage: Route: Time of Administration: Medication 2: _Taken with food? Yes No Dosage: Route: Time of Administration: Medication 3 _Taken with food? Yes No Dosage: Route: Time of Administration: I give permission to the school nurse or other authorized personnel to administer the above medication(s) to my child. Should a change in any of the above information occur, I understand that a revised, written physician s statement and parent authorization must be submitted. Parent/Guardian Signature Date Physician or Nurse Practitioner Name (only required if school will be administering prescription) Date **Signature is required for all medications unless prescribed for a short term. i.e. Amoxicillin for 10 days; pharmacy labeled bottle will suffice.

Pediatric TB Risk Assessment Form (To be completed by medical provider) The purpose of the TB Risk Assessment Form is to identify children who may be at increased risk for tuberculosis (TB) and may require evaluation and testing. A child with any risk factor described below is a candidate for TB testing, unless there is written documentation of a previous positive TB test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]). Child s Name: DOB: Date: TB Risk Assessment Yes No Was the child born in Africa, Asia and Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, the Caribbean or the Middle East? In what country was the child born? Has the child lived or traveled in Africa, Asia and Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, the Caribbean or the Middle East for more than one month? In the last 2 years, has the child lived with or spent time with someone who has been sick with TB? Have any members of the child s household come to the United States from another country? Does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? Test for TB Test, using a TST or IGRA, only those infants and children identified to be at risk of exposure to TB. Do not test infants and children at low risk for TB. IGRA is the preferred test for children 5 years of age and older with a history of BCG vaccination Use the Mantoux tuberculin skin test (5 TU PPD) for children of any age. Report TB Report newly diagnosed cases of latent TB infection and suspected or confirmed TB disease to the Massachusetts Department of Public Health. http://www.mass.gov/eohhs/gov/departments/dph/programs/id/isis/case-report-forms.html Resources Brochure What Parents Need to Know About Tuberculosis (TB) Infection in Children, New Jersey Medical School Global Tuberculosis Institute http://globaltb.njms.rutgers.edu/downloads/products/tbpedsbrochure.pdf Screening Infants and Children for Tuberculosis in Massachusetts, MDPH 2014 http://www.mass.gov/eohhs/docs/dph/cdc/tb/recommendations-screening-children-tb.pdf CDC recommendations on TB evaluation, testing and treatment in children http://www.cdc.gov/tb/topic/populations/tbinchildren/default.htm CDC Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children. MMWR September 2009 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5811a1.htm MDPH supported TB clinics http://www.mass.gov/eohhs/docs/dph/cdc/tb/regional-clinic-list.pdf Medical Provider Signature: Date: Massachusetts Department of Public Health Bureau of Infectious Disease February 2014 Division of Global Populations and Infectious Disease Prevention

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