Palm Beach County School Health Medical History of Student

Palm Beach County School Health

HCDPBC School Health Rev. 7/2004

Medical History of Student with Attention Deficit Disorder (ADD) Attention Deficit Hyperactive Disorder (ADHD)

Parent /Guardian Questionnaire Student: ___________________________DOB____________________ School Year:______________ School:____________________________Gr./Teacher/ESE:_______/______________/_____________ Parent/Guardian:______________________________ Phones (Home)______________ (Work) ______________

Address:____________________________________ (Cell)________________ (Other)______________

Physician: ___________________________________ Phone: _________________________________

Dear Parent/Guardian: School records indicate that your child has a serious medical condition. Please complete the

following questionnaire and return it to me as soon as possible. This will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Call me with any questions or concerns. ________________________ _____________________ ______________ School Nurse Phone Date

1. Has a physician diagnosed your child with ADD/ADHD? No Yes 2. Which of the following behaviors does your child display? (X all the boxes that apply)

ADD- Inattentive Type ADHD- Hyperactive/Impulsive Type

Makes careless mistakes Fidgets with hands or feet and squirms

Difficulty sustaining attention in tasks or play Difficulty remaining seated

Struggles to follow through on instructions Runs or climbs excessively

Does not appear to listen to what is being said Difficulty engaging in activities quietly

Easily distracted Acts as if “driven by a motor”

Difficulty organizing tasks and activities Talks excessively

Forgetful in daily activities Blurts out answers spontaneously

Often loses things necessary for tasks Difficulty waiting in line for their turn

Avoids or dislikes tasks that require mental effort Interrupts or intrudes upon others

3. Methods you use at home to manage attention deficit or hyperactivity issues:

Behavior management style Counseling Medication Diet

Other_______________________________________________________________________

4. Please list the medications your child takes for attention deficit or hyperactivity? everyday and as

needed

Name of Medication Dosage Time In School________________________________________________________________________ ________________________________________________________________________________ At Home _________________________________________________________________________ ________________________________________________________________________________

5. Does your child need any special accommodations related to his/her attention deficit or hyperactivity

while at school or on a field trip? No Yes If Yes Please list them. ________________________________________________________________________________________________________________________________________________________________


HCDPBC School Health Rev. 7/2004

The School Nurse will take the following action if your child has a medical problem

during school hours, unless otherwise indicated

ADD/ADHD Initial Action Plan Assess student‟s physical status

Administer medication as ordered

Evaluate student‟s condition

Send back to class

Send home

Send to health care provider

ADD/ADHD Emergency Care Plan

Serious Signs and Symptoms:

Aggressive behavior

Uncontrolled behavior

Immediate action:

Notify intervention team

Notify parent/guardian designee

Is there any action that would be helpful for your child in case of a medical emergency in school?

___________________________________________________________________________

Please circle appropriate response for each and sign.

I do/ do not give the School Nurse my permission to follow the above emergency measures to assure my child‟s health and safety.

I do/ do not give the School Nurse my permission to contact my child‟ health care provider for information relevant to his/her medical condition as determined appropriate for my child‟s health and safety.

I do/ do not give the School Nurse my permission to share medical information with specific School District staff on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.

________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE

____________________________________________________________________________________________ (Nurse Use Only) Narrative Note: Update the initial questionnaire, yearly with the parent. New parent questionnaire

required only when student transfers to new school or change in child‟s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. _____________________________________________________________________________________________________________________

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Page 1 of

School Year: _____________ School: _______________________________________

Student Name: ____________________________________

Student #

DOB: _______________ Sex: M / F Grade: ____ Teacher: ___________________

Parent(s)/Guardian: _____________________________________ Phone ____________________

Phone ___________________ Phone ______________________ Phone _____________________

Physician______________________________________________ Phone_____________________

1. Does your child have a diagnosis of an allergy from a healthcare provider? No Yes

2. History

3. Trigger and Symptoms What are the early signs and symptoms of your child’s allergic reaction? (Be specific; include things the

student might say.) _____________________________________________________________

________________________________________________________________________

How quickly do symptoms appear after exposure to allergen(s)? ___secs. ___mins. ___hrs. __days

Please check the symptoms that your child has experienced in the past:

Skin: Hives Itching Flushing Rash Swelling (face, arms,

Mouth: Itching Swelling (lips, tongue, mouth) hands, legs)

Abdominal: Nausea Cramps Vomiting Diarrhea

Throat: Itching Tightness Cough Hoarseness

Lungs: Wheezing Repetitive Cough Shortness of breath

Heart: Weak pulse Loss of consciousness

4. Treatment

How have past reactions been treated? ____________________________________________________

How effective was the child’s response to treatment? _________________________________________

Was there an emergency room visit? No Yes, explain:________________________________________

Was the child admitted to the hospital? No Yes, explain:_______________________________________

What treatment or medication has your healthcare provider recommended for use in an allergic reaction? ____________________________________________________________________________________

Has your child’s healthcare provider provided a prescription for medication? No Yes ___________

Has your child used the treatment or medication? No Yes

What is your child allergic to?

Peanuts Insects __________________

Eggs Fish/Shellfish

Milk Tree Nuts (walnuts, pecans, etc.)

Latex Soy

Other: ________________________________

Age of child when allergy first discovered:______

How many times has s/he had a reaction?

Never Once More than one, explain:

________________________________________

Explain their past reaction(s):________________

________________________________________

_

Name___________________________ DOB __________ Weight_______lbs

Page 2 of 2

5. Self Care Does your child: Know what foods/allergens to avoid No Yes Ask adults about food ingredients No Yes

Read and understand food labels No Yes Tell an adult immediately after an exposure No Yes

Wear a medical alert bracelet No Yes Tell peers and adults about the allergy No Yes Does your child know how to use emergency medication? No Yes Has your child ever administered their own emergency medication? No Yes Does your child carry epinephrine in the event of a reaction? No Yes

6. General Health Does your child have a history of asthma? No Yes-(Higher risk of severe reaction) Does your child have other health conditions?_______________________________________________ Hospitalizations?______________________________________________________________________

Allergy Action Plan

Child extremely reactive to the following: _______________________________________________________

Medications Epinephrine(Brand and dose): ________________________ 0.3mg IM 0.15mg IM Antihistamine(Brand and dose):______________________________________________________________ Other (e.g., inhaler-bronchodilator if asthmatic): _________________________________________________ Consent for self administration/self-carry (provided the school nurse determines it is safe and appropriate)

I give the School Nurse my permission to follow the above emergency measures to assure my child's health and safety.

I give the School Nurse my permission to contact my child's health care provider for information relevant to his/her medical condition as determined appropriate for my child's health and safety.

I give the School Nurse my permission to share medical information with school staff on a "need to know" basis, if he/she determines this information is necessary to assure my child's health and safety.

I will notify the School Nurse and teachers if there is any change in medication, treatment or medical condition.

_________________________________________ __________________ Parent/Guardian Signature Date

Any SEVERE SYMPTOMS after suspected or known exposure: One or more of the following:

LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body

Or combination of symptoms from different body areas:

SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, diarrhea, cramping pain

1. Inject epinephrine immediately 2. Call 911 3. Begin monitoring (see box below) 4. Give additional medications;* -Antihistamine -Inhaler (bronchodilator) if asthma

*Antihistamines & inhalers/bronchodilators are not to be depended upon to treat a severe reaction (anaphylaxis) USE EPINEPHRINE.

MILD SYMPTOMS ONLY:

MOUTH: Itchy mouth

SKIN: A few hives around mouth/face, mild itch

GUT: Mild nausea/discomfort

1. Give antihistamine if ordered 2. Stay with student; alert healthcare professionals and parent 3. If symptoms progress (see above), USE EPINEPHRINE 4. Begin monitoring (see box below)

Monitoring Stay with student; alert healthcare professionals and parent. Tell rescue squad epinephrine was given; request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can be given if applicable (See orders). For a severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See back/attached for auto-injection technique.


HCDPBC School Health Rev 8/06 Page 1 of 3 P:\SchHlthAdmin\CarePlans\Asthma

Medical History of Student with Asthma Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________ School________________________________ Gr/Teacher/ESE _________/__________________/ Y/N Parent/Guardian_________________________Phones: Home________________ Work_______________ Address_____________________________________ Cell ________________ Other_______________ Physician_________________________________________ Phone _____________________________

Dear Parent/Guardian: School records indicate your child has a serious health condition. Please complete the following

questionnaire and return it to me as soon as possible. This will help us to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will

become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Call me with any questions or concerns.

___________________________________________ ______________________ _____________________ SCHOOL NURSE PHONE DATE

1. Has your child been diagnosed by a physician? How often does your child have an asthma attack?

______________________________________________________________________________________________________________________________________

2. Has your child been hospitalized for asthma? No Yes If yes, when? ___________________ 3. What triggers your child‟s asthma attacks? (X all boxes that apply)

Pollen Animal dander Cigarettes smoke Vigorous exercise

Mold Perfume Respiratory infection Dust

Coughing Fumes Cold Air Feathers

Air pollution Weather changes Foods (specify) ___________ Other _____________

4. What symptoms does your child experience during an attack? ________________________________ ________________________________________________________________________________

________________________________________________________________________________

5. Please list the medications your child takes for his asthma - everyday and as needed. Name of Medication Route Dosage Time In School________________________________________________________________________ ________________________________________________________________________ At Home ________________________________________________________________________ ________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child‟s medications or treatments? □ Yes □ No If no, please see the school nurse.

6. Does your child use a spacer with an inhaler? No Yes A nebulizer machine? No Yes

7. Does your child use a peak flow meter? No Yes If yes, what is his/her personal best? __________________________________________________

8. Does your child need any special considerations/accommodations related to his/her condition while at

school or on a field trip? No Yes If yes, please list __________________________________ _____________________________________________________________________________

9. Has your child attended any asthma education classes? No Yes If yes, were these classes held

at school? ______ Has your child benefitted from this education? No Yes If yes, please describe ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________





Asthma Initial Action Plan

Place student in a comfortable sitting position

Assess student‟s physical status, vital signs including respiratory rate and lung sounds, and recent medication use

Administer medication sequentially, if ordered by physician (i.e. inhaled medication first, then nebulized medication as ordered, if necessary)

Wait at least 5 – 10 minutes for medication to take effect

Keep child calm; give sips of tap water

Within 15 – 30 minutes after medication (bronchodilator) has been administered, re-evaluate student‟s condition and determine if student should be sent back to class, sent home or sent to healthcare provider

If there has been no improvement in the student’s condition during this time, treat as urgent:

If stable – call parent to transfer immediately to healthcare provider

If unstable – proceed to Emergency Care Plan

ASTHMA EMERGENCY CARE PLAN

Serious Signs and Symptoms: Nasal flaring

Shallow, rapid respirations, unable to talk

Tightening of neck & chest muscles with each inhalation

Absence of wheezing, severe retractions and prolonged expirations

Blue or gray coloring of lips & nail beds

Rapid heart beat

Low blood pressure

Immediate action Call 911

Notify parent/guardian/designee

Notify healthcare provider

If transported, nurse to call Emergency Room staff with nursing report, designee can provide student health information

Is there any other action that would be helpful for your child in case of a medical emergency in school?

______________________________________________________________________ Please circle appropriate response for each and sign below.


I do/ do not give the School Nurse my permission to contact my child‟s healthcare provider for information relevant to his/her medical condition as determined appropriate for my child‟s health and safety.

I do/ do not give the School Nurse my permission to share medical information with specific school staff on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.

__________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE

__________________________________________________________________________________________ (Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only

when student transfers to new school or change in child‟s medical management or activity levels. Document findings

in a brief narrative note, sign and date, followed with case note in Welligent. Time

Narrative Note:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

□ Transferred to: ___________________________________



□ Unable to make contact with parents:


HCDPBC School Health Rev 10-11-04 Page 1 of 4 P:\SchHlthAdmin\CarePlans

Medical History of Student with Cancer Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________ School________________________________ Gr/Teacher/ESE _______/________________/________ Parent/Guardian______________________________ Phones (Home)___________________________ (Work)______________________(Cell)__________________________ (Other)____________________ Physician_________________________________________ Phone _____________________________ Dear Parent/Guardian: School records indicate that your child has a serious medical condition. With your child’s health and safety in mind, please complete the following questionnaire and return it to me as soon as possible. This will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child’s confidential school health medical record. With your written consent, I will share this information with specific school personnel on a ‘need to know’ basis only. Please keep me informed of any changes in your child’s condition or medication. Call me with any questions or concerns. _______________________________ ____________________ ________________ SCHOOL NURSE PHONE DATE 1. Describe your child’s current medical condition. Please include any diagnosis used by your child’s

physician. Diagnosis:________________________________________________________________________________________________________________________________________________________ Current Condition:__________________________________________________________________ ________________________________________________________________________________

2. Please describe any special needs your child has as a result of this condition, including any

equipment, restrictions or assistance necessary during the school day. ________________________________________________________________________________ ________________________________________________________________________________

3. Has your child been hospitalized for this condition? � No ��Yes If yes, when? _______________________ How long was the hospital stay? __________________

4. Is your child undergoing outpatient treatment at this time? � No � Yes 5. Is your child familiar with his/her medical condition?

________________________________________________________________________________ ________________________________________________________________________________ 6. Have there been any nutrition problems (special diets and/or weight loss)?

________________________________________________________________________________________________________________________________________________________________

7. Does your child have any medical devices implanted or intravenous access sites? � No � Yes If yes, where is the location? _________________________________________________________ ________________________________________________________________________________



8. Does your child have any pain or medication for pain? ��No � Yes Please list the medications your child takes - everyday and as needed.

Name of Medication Dosage Time In School________________________________________________________________________ ________________________________________________________________________ At Home ________________________________________________________________________ ________________________________________________________________________ What, if any, side effects from medication does your child show? ____________________________ ________________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child’s medications or treatments? � Yes � No If no, please see the school nurse. 9. Does your child need any special considerations/accommodations related to his/her condition while

on a field trip? � No � Yes If yes, please list:________________________________________ ________________________________________________________________________________ Are there any special dietary requirements?______________________________________________ ________________________________________________________________________________

10. Does your child understand and participate in management of his/her medical condition? � Totally responsible � Needs reminding � Unable/non-compliant 11. Is there any other information you would like us to know about your child’s condition? _________________________________________________________________________________ _________________________________________________________________________________



Student name_________________________ DOB________________ School_____________________

The School Nurse will take the following action if your child has a medical problem during school hours, unless otherwise indicated

Cancer Initial Action Plan

• Monitor and record the student’s orientation and state of health • Physical examination – review • General – orientation, state of health • Specific – known medical problems

• Provide – immediate intervention as needed • History – if student is able, obtain current medical history including recent

interventions such as chemotherapy, radiation treatment, etc. • Determine if student should be:

• Sent back to class • Sent home and/or • Send to health care provider.

• Notify parent/guardian • If condition worsens, proceed to the Emergency Care Plan

CANCER EMERGENCY CARE PLAN

Serious Signs and Symptoms: Injury: Excessive bruising, joint pain, Bleeding, Fever over 100.5 F Volume Deficit: Nausea, vomiting, diarrhea Heat exposure Gastrointestinal, oral conditions Skin integrity Intact skin Pain: Increased pain Related to diagnosis, treatment, physiologic effects of neoplasm

Immediate action to take: • Call 911 • Notify parent/guardian/designee • Notify health care provider • If transported, nurse to call Emergency Room

staff with nursing report, designee can provide student health information

Is there any other action that would be helpful for your child in case of a medical emergency in school? ____________________________________________________________________________________________________________________________________________



Please circle appropriate response for each and sign below. • I do/ do not give the School Nurse my permission to follow the above emergency measures to

assure my child’s health and safety. • I do/ do not give the School Nurse my permission to contact my child’ health care provider for

information relevant to his/her medical condition as determined appropriate for my child’s health and safety.

• I do/ do not give the School Nurse my permission to share medical information with specific School District staff on a “need to know” basis, if he/she determines this information is necessary to assure my child’s health and safety.

____________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE

(Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child’s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. Narrative Note: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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Palm Beach County School Health Program

HCDPBC School Health Rev 9/06 Page 1 of 2 P:\SchHlthAdmin\CarePlans\Cardiac

Medical History of Student with Cardiovascular Disorder(s) Parent /Guardian Questionnaire

Student _____________________________________DOB________________ School Year _________

School______________________________________Gr./Teacher/ESE________/______________/ Y/N

Parent/Guardian ______________________________Phones: Home______________Work__________

Address_____________________________________Cell_______________Other_________________

Physician ____________________________________Phone __________________________________

Dear Parent/Guardian: According to health information you provided, school records indicate that your child has or has

had in the past a cardiovascular disorder that may require some observations, treatment or specific considerations in the school setting. Please complete the following questionnaire and return it to me as soon as possible. This will help us to determine any specific health care needs your student may have in school so that your child remains healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medications. Always call me with any questions or concerns. Sincerely, ___________________________ ___________________ ________________ SCHOOL NURSE PHONE DATE 1. What type of cardiovascular disorder does your child have? (X all boxes that apply)

□ Aortic stenosis □ Coarctation of the aorta □ Congestive heart failure □ Hypertension □ Murmur

□ Patent ductus arteriosis □ Rheumatic heart disease □ Septal defect □ Tetralogy of Fallot

□ Transposition of the great arteries Any cardiac surgeries? □ No □Yes If yes, how many surgeries? ____________ What did the surgery repair or correct? ____________________________ __________________________________________Date(s) ________________________________

□ Other (Specify) _________________________________________________________________

2. Your child‟s signs and symptoms of cardiac distress are: (X all boxes that apply)

□ Chest tightness or pain □ Shortness of breath or difficulty breathing easily □ Tires easily

□ Occasional irritability □ Change in activity tolerance □ Paleness of skin □ Fainting or dizziness □ Blue or gray color around mouth, lips, or fingernails □ Can your student run, jump, play ball as

normal for his/her age? □ No □Yes □ Other information _________________________________

3. Does your child have any activity or dietary restrictions? □ No □ Yes (Doctor‟s letter is required if

activity is limited) Be specific _______________________________________________________

4. How often does your child have symptoms? Last time ______________________________ Weekly____________ Monthly_____________________Never____________________________

Has your child ever been hospitalized? □ No □ Yes If yes, when_________________________

5. Please list the medications your child takes (everyday and as needed). Name of Medication Route Dose Frequency In school________________________________________________________________________ At home ________________________________________________________________________

Do you understand the medication/treatment authorization form needed for your child‟s medications or treatments? □ Yes □ No If no, please see the school nurse.

6. Does your child understand and participate in the management of his/her disorder?

□ Totally responsible □ Needs reminding □ Uncooperative/Non-compliant

Have you ever attended a cardiac education class? □ No □ Yes Has your child attended a cardiac education class? □ No □ Yes

7. Does your child need any special considerations or accommodations related to his/her medical condition while at school or on a field trip? □ No □ Yes If yes, please list them ______________________________________________________________


HCDPBC School Health Rev 9/06 Page 2 of 2 P:\SchHlthAdmin\CarePlans\Cardiac

The School Nurse will take the following action if your child has a medical emergency during school hours, unless otherwise indicated.

Cardiac Initial Action Plan

Place the student in a comfortable position

Assess and record the student‟s ABCs, physical status and vital signs

Administer any prescribed medication

Wait at least 5-10 minutes for the medication to take effect

Keep the child calm

Re-evaluate student‟s condition and determine:

Return to class

Sent home and/or

Send to healthcare provider

Notify parents/guardian

If condition worsens or fails to improve, proceed to the Emergency Care Plan

CARDIAC EMERGENCY CARE PLAN

Serious signs and symptoms: Severe chest pain

Shortness of breath (air hunger)

Tingling and numbness of hands or feet

Cyanosis ( lips and nail beds turn grayish or bluish color)

Tachycardia (increased heart rate)

Symptomatic bradycardia (decreased heart rate)

Increased blood pressure

Edema

Immediate action to take: Call 911




Is there any other action that would be helpful for your child in case of a medical emergency in school? ____________________________________________________________________________________


(I do/ do not) give my permission for the School Nurse to take all the above emergency measures for my child‟s (name)______________________________________ health and safety.

(I do/ do not) give my permission for the School Nurse to contact the healthcare provider for information relevant to his/her medical condition as determined appropriate for my child‟s health and safety.

(I do/ do not) give the School Nurse my permission to share information relevant to my child‟s medical status, with appropriate school personnel on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety during school hours.

______________________________________________ ________________________ PARENT/GUARDIAN SIGNATURE DATE

(Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child‟s medical management. Document a brief narrative note, sign and date, followed with case note in Welligent. Narrative Note:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

□ Transferred to: _________________________________________________ (School)

□ Unable to make contact with parents to discuss student‟s health condition

□ Dates/times of contact attempts_________________________________________________________


HCDPBC School Health Rev. 10-11-04 Page 1 of 2 P:\SchHlthAdmin\CarePlans

Medical History of Student with Cystic Fibrosis Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________ School____________________________Gr./Teacher/ESE_____________/______________/________ Parent/Guardian__________________________________ Phone (Home)________________________ (Work)_____________________(Cell) _______________________(Other) _______________________ Physician_________________________________________________Phone _____________________

Dear Parent/Guardian: School records indicate that your child has a serious medical condition. With your child’s health and safety in mind, please complete the following questionnaire and return it to me as soon as possible. This will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child’s confidential school health medical record. With your written consent, I will share this information with specific school personnel on a ‘need to know’ basis only. Please keep me informed of any changes in your child’s condition or medication. Call me with any questions or concerns. ____________________________ ______________________ _____________________ SCHOOL NURSE PHONE DATE 1. When was your child diagnosed with cystic fibrosis? _______________________________ 2. Has your child ever been hospitalized for cystic fibrosis? ��No � Yes

If yes, when ___________________________________________________________

3. Please check off the things that are included in your child’s CF management plan:

� chest physical therapy � physical activity � dietary management � child and family education � medications

4. Does your child understand and participate in management of his/her cystic fibrosis?

��Totally Responsible � Needs Reminding � Unable/Non-compliant 5. Please list the medications your child takes for cystic fibrosis - everyday and as needed. Name of Medication Dosage Time In School_______________________________________________________________________ ________________________________________________________________________ At Home _______________________________________________________________________ ________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child’s medications or treatments? � Yes � No If no, please see the school nurse. 6. Have you or your child attended any Cystic Fibrosis Foundation educational classes? � No � Yes 7. Does your child need any special considerations/accommodations related to his/her cystic

fibrosis disorder while in school or on a field trip? � No � Yes If yes, please list __________________________________________________________ _________________________________________________________________________ __________________________________________________________________________________________


HCDPBC School Health Rev. 10-11-04 Page 2 of 2 P:\SchHlthAdmin\CarePlans

Student name________________________ DOB______________ School______________________

The School Nurse will take the following action if your child has a medical problem during school hours, unless otherwise indicated

Cystic Fibrosis Initial Action Plan

� Place student in a comfortable sitting position � Assess and record student’s physical status, vital signs including lung sounds � Administer medication as ordered � Evaluate and student’s condition to determine if student should be:

• Sent back to class • Sent home • Sent to health care provider

� If respiratory condition worsens, proceed to Emergency Care Plan

CYSTIC FIBROSIS EMERGENCY CARE PLAN Serious Signs and Symptoms: • Shortness of breath • Unable to clear airway • Nasal flaring • Rapid heart rate

Immediate Action: • Call 911 • Notify parent/guardian/designees • Notify health care provider • If transported, nurse to call Emergency Room

staff with nursing report, designee to provide student health information

Is there any other action that would be helpful for your child in case of a medical emergency in school? ______________________________________________________________________ ____________________________________________________________________________________ Please circle appropriate response for each and sign. • I do/ do not give the School Nurse my permission to follow the above emergency measures to




___________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE _____________________________________________________________________________________________ (Nurse Use Only) Narrative Note: Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child’s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. _____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

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Medical History of Student with Depression Disorder Parent /Guardian Questionnaire

Student_______________________________DOB________________School Year_____________ School____________________________Gr./Teacher/ESE____________/______________/_____ Parent/Guardian________________________________ Phone (Home) ______________________ (Work) _____________________ (Cell) ____________________ (Other) _____________________ Physician________________________________________________ Phone __________________ Dear Parent/Guardian: School records indicate that your child has a serious health condition. With your child’s health and safety in mind, please complete the following questionnaire and return it to me as soon as possible. This will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child’s confidential school health medical record. With your specific written consent, I will share this information with specific school personnel on a strict ‘need to know’ basis only. Please keep me informed of any changes in your child’s condition or medication. Call me with any questions or concerns. ______________________________ ______________________ _____________________ SCHOOL NURSE PHONE DATE 1. How long has your child been diagnosed with depression? _____________________________________

____________________________________________________________________________________ 2. Has your child been seen by a psychiatrist? � No � Yes If yes, what was the date of the last visit? _______________��

�

3. Has your child’s medical condition improved or deteriorated either now or in the past? � No � Yes If yes, how has it changed? ______________________________________________________________ ____________________________________________________________________________________ 4. Do you have any immediate needs for assistance with your child’s medical condition? � No � Yes

If yes, what are those needs? ____________________________________________________________ ____________________________________________________________________________________ The following information will help me understand more about your child’s condition. Together we can help your child in school.

5. What triggers your child’s problems? (X all boxes that apply) Significant recent life changes such as: � Moving/ new school � Financial issues � Physical illness � Mental illness

� Chemical/ drug abuse � Alcohol abuse � Parent separation/ divorce � Loss of parent

� History of physical, sexual, or emotional abuse and/or neglect � Social issues

6. What are your child’s symptoms? (X all boxes that apply) � Sad or bored mood � Disinterested in most activities � Significant weight loss or gain

� Diminished concentration � Always tired OR very active � Feelings of worthlessness or guilt

� Sleep disturbance � Recurrent thoughts of death or suicide � Hostile or aggressive behavior

� Other (Specify) ___________________________________________________________________________



7. Has your child ever been hospitalized for emotional or behavioral problems? � No � Yes If yes, when __________________________________________________________________________ 8. Please list the medications your child takes for these emotional or behavioral problems – everyday and as needed. Name of medication Dose Time In School ____________________________________________________________________________

____________________________________________________________________________________ At Home _____________________________________________________________________________

____________________________________________________________________________________

9. Does your child need any special accommodations related to his/ her problem while: A) at school in classes � No � Yes

B) on a field trip � No � Yes

C) any other time at school � No � Yes If yes, please list them _________________________________________________________________

____________________________________________________________________________________



Student_____________________________DOB_______________School____________________

The School Nurse will take the following action if your child has a medical problem during school hours, unless otherwise indicated.

Emotional/Behavioral Problem Initial Action Plan

1. Provide privacy and remain with the student 2. Listen to what is troubling the student 3. Help student explore possible solutions 4. Utilize school-based counseling/support group 5. Notify parent of student’s condition 6. Refer for ongoing counseling 7. Re-evaluate student’s condition and determine:

a) Send back to class b) Send home and/or c) Send to health care provider

8. If condition worsens, proceed to the Emergency Care Plan

EMOTIONAL/BEHAVIORAL EMERGENCY CARE PLAN Serious Signs and Symptoms: • Inability to control emotions/behavior • Physical threat to themselves or others * See Suicide Prevention Algorithm for further assistance

Immediate Action: • Notify parent/guardian/designee • Notify principal • Arrange for immediate assessment by

mental health center or emergency healthcare facility

• Call Emergency room with report

Is there any other action that would be helpful for your child in case of a medical emergency in school? Please circle appropriate response for each and sign. • I do/ do not give the School Nurse my permission to follow the above emergency measures to assure my

child’s health and safety. • I do/ do not give the School Nurse my permission to contact my child’ health care provider for information

relevant to his/her medical condition as determined appropriate for my child’s health and safety. • I do/ do not give the School Nurse my permission to share medical information with specific School

District staff on a “need to know” basis, if he/she determines this information is necessary to assure my child’s health and safety.

________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE ____________________________________________________________________________________________ (Nurse Use Only) Narrative Note: Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child’s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. __________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

______________________________ ___________________________________________________________________________________________



��

EMERGENT � Thoughts of death � Suicide plan � Suicide attempt � Previous suicide attempt

NON-URGENT � Frequent physical

complaints � Sad affect

Focused Psychosocial Examination/Risk Factor Assessment Psychiatric risks � Psychiatric/behavioral disorder � Previous suicide attempt � Family psychiatric history � Alcohol/other drug addiction Situational risks � Firearms at home � Gang involvement � Exposure to suicide � History of abuse � Interpersonal conflicts � Disrupted romantic attachment � Disrupted family or loss of loved one

Affective signs � Sad/depressed � Moody/crying � Extreme irritability � Hopelessness Behavioral signs � Sudden behavior changes � Withdrawal from friends/family/activities � Giving away possessions � Threatening to harm self � Neglects appearance � Impaired school performance � Frequent tardiness/absence

Cognitive signs � Preoccupation with death � Writing/artwork about

death/suicide � Impaired concentration � Refers to “going away” Physical signs � Frequent physical complaints � Frequent headaches � Sleep disturbances � Appetite disturbances � Fatigue

Triage

Assessment of Immediate Danger � Suicidal ideation � Suicide plan, intent, method � Suicide preparations � Previous attempt to hurt/kill self (timing, circumstances of previous

attempt)

URGENT � Depression � Withdrawal � Self-blame � Self-reproach

� Closely observe student � Listen to student � Determine need for EMS � Remain with student at

all times � Refer to crisis

management team � Notify parent/guardian

and school authority � Follow up/monitor

behavioral progress

� Observe student regularly

� Initiate/refer for counseling

� Immediately inform student’s family, teacher, and crisis management team of your concerns and findings

� Follow up/monitor behavioral progress

� Activate EMS � Continually/closely observe

student Do not leave student alone under any circumstances!

� Listen to student carefully � Take conversation seriously � Refer to crisis management

team � Notify parent/guardian and

school authority � Follow up/monitor behavioral

progress

� Assess ABCs � Assess vital signs � Obtain history � Conduct initial assessment

The School Nurse Task Force of the Illinois Emergency Medical Services for Children has exercised extreme caution that all information presented is accurate and in accordance with professional standards in effect at the time of publication. The information does not serve as a substitute for the professional advice of a physician; does not dictate an exclusive course of treatment; and should not be construed as excluding other acceptable methods of treatment. It is recommended that care must be based on the child’s clinical presentation and on authorized policies.


HCDPBC School Health Rev 8/06 Page 1 of 2 P:\SchHlthAdmin\CarePlans\Diabetes

Medical History of Student with Diabetes Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________

School________________________________Gr/Teacher/ESE ____________/________________/ Y/N

Parent/Guardian___________________________Phone: Home _______________ Work_______________

Address_____________________________________ Cell__________________ Other ________________

Physician_________________________________________ Phone _____________________________

Dear Parent/Guardian: School records indicate your child has a history of diabetes. In order to manage diabetes in the school setting, please complete the following questionnaire and return it to me as soon as possible. This will help us to determine any special needs your child may have in school; together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Call me during school hours with any questions or concerns. Sincerely, _______________________________ ____________________ ________________ SCHOOL NURSE PHONE DATE

1. When was your child diagnosed with diabetes? ___________________________________________

2. Describe your child‟s symptoms relating to diabetes. (X all boxes that apply) Hypoglycemia (Common causes - too little food, too much medication, more than usual exercise)

□ Rapid heart rate □ Weakness □ Shaking □ Sweating □ Fatigue □ Irritability □ Sleepiness □ Hunger

□ Dizziness □ Anxiety □ Headache □ Slurred speech □ Other _________________________________

Hyperglycemia

(Common causes – too much food, too little medication, illness, stress, blood glucose greater than 240 mg/dl)

□ Extreme thirst □ Hunger □ Blurred vision □ Drowsiness □ Irritability □ Nausea □ Dry skin □ Frequent urination □ Severe headache □ Illness □ Other _________________________________________

3. Has your child experienced a diabetic coma/insulin reaction? □ No □ Yes If yes, when?_____________

4. Has your child ever been hospitalized for diabetes? □ No □ Yes If yes, when and why? ______________ ________________________________________________________________________________

5. Please list the medications your child takes – every day and as needed. Name of Medication Route Dosage Time

In School _________________________________________________________________________ _________________________________________________________________________ At Home _________________________________________________________________________ _________________________________________________________________________ What, if any, side effects from medication does your child show? _____________________________ _________________________________________________________________________________

6. Does your child need any special accommodations related to his/her diabetes while in school or on a field trip?

□ No □ Yes If yes, please list _______________________________________________________________

________________________________________________________________________________

7. Does your child understand and participate in management of his/her diabetes? □ Totally responsible □ Needs reminders □ Unable/non-compliant

8. Does your child exercise regularly? □ Yes □ No □ Sometimes

9. Is there any other information you would like us to know about your child‟s condition?

___________________________________________________________________


HCDPBC School Health Rev 8/06 Page 2 of 2 P:\SchHlthAdmin\CarePlans\Diabetes


Diabetes Initial Action Plan Location of supplies

Assess and record student‟s physical status, including 1. Glucometer ____________________ ABC‟s, vital signs, blood glucose level, last insulin dose/meal 2. Snacks _______________________

Administer food as ordered, if appropriate 3. Drinks ________________________

Administer medication as ordered 4. Insulin _______________________

Notify parent/guardian 5. Syringes _____________________

Reevaluate student‟s condition and determine whether student 6. Glucose tablets/gel ______________ should return to class, stay in health room, or be sent home c/o 7. Glucagon ______________________ parent and/or to healthcare provider 8. Ketone sticks ___________________

If condition worsens, proceed to the Emergency Care Plan

DIABETIC EMERGENCY CARE PLAN Serious Signs and Symptoms: Hypoglycemia Rapid heart rate

Shaking

Sweating, dizziness

Anxiety, irritability

Headache

Weakness, fatigue

Hunger

Sleepiness

Slurred speech

Hyperglycemia Extreme thirst, hunger

Frequent urination

Drowsiness, irritability

Severe headache

Nausea

Blurred vision

Dry skin

Illness

Immediate action to take: Follow emergency response orders on

Physician Authorization for Diabetes Medication


Call 911




See Desktop Guide to Emergency Care and Injury Response – Page 19

Is there any other action that would be helpful for your child in case of a medical emergency in school? _______________________________________________________________________________________

_________________________________________________________________ Please circle appropriate response for each and sign below.



I do/ do not give the School Nurse my permission to share medical information with specific school personnel on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.

I understand that the School Nurse can only accept changes in my child‟s medication or treatment orders from my child‟s healthcare provider.

__________________________________ _______________ PARENT/GUARDIAN SIGNATURE DATE _________________________________________________________________________________________________ (Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or changes in child‟s medical management are made. Document a brief narrative note, sign, and date, followed with case note in Welligent. Narrative Note: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

□ Transferred to: _____________________________________________________________________

□ Unable to make contact with parents: ___________________________________________________


HCDPBC School Health Rev 7/2004

Medical History of Student with Hemophilia Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________ School____________________________Gr/Teacher/ESE__________/_________________/_________ Parent/Guardian___________________________Phone (Home) _____________ (Work) ____________ Address_____________________________________(Cell) _____________ (Other) ________________ Physician_________________________________________________Phone _____________________

Dear Parent/Guardian: School records indicate your child has a serious health condition. Please complete the following questionnaire and return to me as soon as possible. This will help us to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your condition or medication. Call me with any questions or concerns. ______________________________ ______________________ _____________________

SCHOOL NURSE PHONE DATE

1. Tell me about your child‟s Hemophiliac condition.

Type of Hemophilia: (X the box that applies) Hemophilia A Hemophilia B Von Willebrand‟s disease

2. What is the severity of the hemophilia? (X the box that applies)

Mild Moderate Severe

3. Describe the usual bleeding pattern. _____________________________________________________________________________

_____________________________________________________________________________

4. What has been the usual result of the bleeding episodes? _____________________________________________________________________________

5. Describe past experiences with bleeding episodes at home and in school. When was the last episode? _____________________________________________________________________________

_____________________________________________________________________________

6. Please list the medications your child takes for hemophilia – everyday and as needed.

Name of Medication Dosage Time

In School_____________________________________________________________________

______________________________________________________________________

At Home _____________________________________________________________________

______________________________________________________________________

7. Please describe any special needs your child has during the school day as a result of this condition.

Special treatments: ____________________________________________________________

Activity restrictions for classroom or physical education:________________________________ Field trip accommodations: ______________________________________________________ Assistance or other needs: _______________________________________________________


HCDPBC School Health Rev 7/2004


during school hours, unless otherwise indicated.

Hemophilia Initial Action Plan Place child in a comfortable position

Assess student‟s physical status, including vital signs

Re-evaluate student‟s condition:

Send back to class

Send home

Send to health care provider

Call parent or guardian


HEMOPHILIA EMERGENCY CARE PLAN

Serious Signs and Symptoms: Blueness or discoloration of the skin

Double or blurred vision

Difficulty swallowing, breathing

Signs/sxs of head injury

Warmth in a joint

Numbness in a limb Gradually intensifying pain

Immediate Action to take: Follow emergency response orders on Physician

Authorization Form

Notify parent/guardian

Based on nursing assessment, call 911 and/or health care provider

If transported, call Emergency Room with report

Is there any other action that would be helpful for your child in case of a medical emergency in school? _____________________________________________________________________________________________



I do/ do not give the School Nurse my permission to contact my child‟ health care provider for information relevant to his/her medical condition as determined appropriate for my child‟s health and safety.

I do/ do not give the School Nurse my permission to share medical information with specific School District staff on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.

___________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE

_____________________________________________________________________________________________ (Nurse Use Only) Narrative Note: Update the initial questionnaire, yearly with the parent. New parent questionnaire

required only when student transfers to new school or change in child‟s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. _____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________



Medical History of Student with Immunodeficiency Disease Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________

School____________________________Gr/Teacher/ESE_____________/______________/_________

Parent/Guardian_________________________________ Phone (Home) _________________________

(Work)_____________________(Cell) __________________________ (Other) ____________________

Physician ______________________________________________ Phone _____________________

Dear Parent/Guardian:

School records indicate that your child has a serious medical condition. With your child’s health and safety in mind, please complete the following questionnaire and return it to me as soon as possible. This

will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child’s confidential school health medical record. With your written consent, I will share this information with specific school

personnel on a ‘need to know’ basis only. Please keep me informed of any changes in your child’s condition or medication. Call me with any questions or concerns. _________________________________________________ ____________________________________ ________________ SCHOOL NURSE PHONE DATE

1. Describe the signs and symptoms of an infection, as it affects your child.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

2. Describe the first episode of an infection as well as date of illness.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

3. Please list the medications your child takes (everyday and as needed).

Medication Dosage Time

In School _________________________________________________________________________________

_________________________________________________________________________________

At Home _________________________________________________________________________________

_________________________________________________________________________________

Do you understand the medication

List any medication-related side effects seen in your child.__________________________________________

4. List all special accommodations related to this condition that must be addressed in school or on a field trip.

• Special diet needs, snacks ________________________________________________________________

• Modifications in physical activity in classroom, PE ______________________________________________

• Other _________________________________________________________________________________



Student _______________________________DOB________________ School____________________



Immunodeficiency Disease Initial Action Plan • Assess the student’s physical status

• Keep the student calm

• Re-evaluate student’s condition:

• Send back to class

• Send home

• Send to doctor or hospital

• Call parent or guardian

• If condition worsens, proceed to the Emergency Care Plan

IMMUNODEFICIENCY EMERGENCY CARE PLAN Serious Signs and Symptoms

• Fever/chills

• Swollen glands

• Fatigue

• Pain

• Nasal congestion or drainage

• Headache

• Cough

• Muscle aches

• Rash

• Other symptoms specific to this student

Immediate Action to Take • Follow emergency response order on Physician

Authorization • Call 911

• Notify parent/guardian/designee

• Notify health care provider

• If transported, call Emergency Room with report

Is there any other action that would be helpful for your child in case of a medical emergency in school? ______________________________________________________________________ Please circle appropriate response for each and sign. • I do/ do not give the School Nurse my permission to follow the above emergency measures to assure my child’s

health and safety.

• I do/ do not give the School Nurse my permission to contact my child’ health care provider for information relevant to his/her medical condition as determined appropriate for my child’s health and safety.


____________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE _________________________________________________________________________________________________________

(Nurse Use Only) Update the initial questionnaire yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child’s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. Narrative Note:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________



Medical History of Student with Inflammatory Bowel Disease Parent /Guardian Questionnaire

Student _______________________________DOB________________ School Year________________ School___________________________________ Gr/Teacher/ESE _______/______________/______ Parent/Guardian______________________________ Phones (Home)___________________________ (Work)_____________________ (Cell) ___________________________ (Other) __________________ Physician______________________________________ Phone ________________________________ Dear Parent/Guardian: School records indicate that your child has a serious medical condition. With your child’s health and safety in mind, please complete the following questionnaire and return it to me as soon as possible. This will help to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child’s confidential school health medical record. With your written consent, I will share this information with specific school personnel on a ‘need to know’ basis only. Please keep me informed of any changes in your child’s condition or medication. Call me with any questions or concerns. _______________________________ ____________________ ________________ SCHOOL NURSE PHONE DATE 1. What is your child’s specific diagnosis and when was it made? (X the box that applies)

��Inflammatory bowel disease � Other_______________________________________________

��Ulcerative colitis

� Crohn’s disease Date diagnosed: ________________________

2. Please describe any special needs your child has during the school day as a result of this condition. Fluid requirements: _____________________________________________________________

Dietary supplements/weight loss issues: _____________________________________________

Food intolerances: ______________________________________________________________

Treatments: ___________________________________________________________________

Supplies or equipment: __________________________________________________________

Assistance needed: _____________________________________________________________

Activity restrictions: _____________________________________________________________

Field trip accommodations: _______________________________________________________

3. Does your child have frequent episodes of this condition? � No � Yes When was the last episode? ______________________________________________________

4. Does your child experience discomfort with this condition? � No � Yes What are the symptoms? ________________________________________________________ How is the discomfort managed? __________________________________________________

5. Please list the medications your child takes - everyday and as needed. Name of Medication Dosage Time In School________________________________________________________________________ ________________________________________________________________________ At Home ________________________________________________________________________ ________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child’s medications or treatments? � Yes � No If no, please see the school nurse. 6. Does your child understand and participate in management of his/her medical condition? � Totally responsible � Needs reminding � Unable/non-compliant 7. Is there any other information you would like us to know about your child’s condition?

________________________________________________________________________________________________________________________________________________________________



Student name_________________________ DOB___________________ School__________________


Inflammatory Bowel Disease Initial Action Plan • Evaluate and record student’s condition and determine if the student should be:

• Sent back to class • Sent home and/or • Sent to health care provider

• Notify parent/guardian • If condition worsens, proceed to the Emergency Care Plan

INFLAMMATORY BOWEL DISEASE EMERGENCY CARE PLAN

Serious Signs and Symptoms: • Severe pain – sharp and localized • Vomiting/diarrhea • Temperature greater than 100.5 F • Blood in stool • Signs of dehydration: Extreme thirst Decreased urine output

Immediate action to take: • Call 911 • Notify parent/guardian/designee • Notify health care provider • If transported, nurse to call Emergency Room

staff with nursing report, designee can provide student health information

Is there any other action that would be helpful for your child in case of a medical emergency in school? ______________________________________________________________________ Please circle appropriate response for each and sign below. • I do/ do not give the School Nurse my permission to follow the above emergency measures to




____________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE _______________________________________________________________________________________________________ (Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child’s medical management. Document findings in a brief narrative note, sign and date, followed with case note in Welligent. Narrative Note: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

________________________________________________________________________________________________________

For Use Only With Student Permission


HCDPBC School Health Rev 8/06 Page 1 of 2 P:\SchHlthAdmin\CarePlans\TeenPregnancy

Medical History of Student with Teen Pregnancy Parent /Guardian Questionnaire

Student ____________________________________DOB__________________ School Year__________________ School_____________________________________Gr./Teacher/ESE_____________/___________________/ Y/N Parent/Guardian______________________________Phone: Home _________________ Work_________________ Address ____________________________________Cell ______________________ Other ___________________ _____________________________________________________________________________________________Physician ________________________________________________ Phone _______________________________

Dear Parent/Guardian: Because your student is now pregnant, it is important that we work together with her doctor to ensure she stays healthy, well, and remains in school. Students with continued support during pregnancy have better health and educational outcomes for themselves and their babies. Together with school staff we can support your daughter in school. Please complete this questionnaire and return it to me as soon as possible. This will help to determine any special health and educational needs that have to be addressed. This medical information will become part of your student’s confidential school health medical record. Please assist me by keeping me informed of any changes in your student’s condition. Don’t hesitate to call me with any questions or concerns. Sincerely, ____________________________ _________________________ _________________ SCHOOL NURSE PHONE DATE 1. What medical conditions does your student have that might cause problems with the pregnancy?

(Examples: diabetes, asthma, seizures, sickle cell disease)__________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

2. Does your student have a healthcare provider (doctor) for her pregnancy? □ No □ Yes

3. Do you need assistance finding a doctor for your daughter? □ No □ Yes

4. Please name the healthcare provider and office location. ___________________________________________ _________________________________________________________________________________________

5. What current medical problems is your student experiencing with this pregnancy? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. What community support services such as parenting classes, food stamps, WIC, SOBRA, Medicaid, etc. would be of help to your student?____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

7. Does your student need any special accommodations related to her pregnancy while at school or on a field trip?

□ No □ Yes Please describe: ______________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

8. Monitoring weight gain during pregnancy is very important. Is your student knowledgeable about eating a well- balanced and nutritious diet for a pregnant adolescent, taking prenatal vitamins, exercising and having sufficient

rest ? □ No □ Yes Explain:_________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

9. We are here to help, what kind of help or information do you need (if any) to assist with your student’s

pregnancy?________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

For Use Only With Student Permission


HCDPBC School Health Rev 8/06 Page 2 of 2 P:\SchHlthAdmin\CarePlans\TeenPregnancy

Student name_____________________________ DOB_________________ School________________________

The School Nurse will take the following action if your student has a medical problem during school hours, unless otherwise indicated.

Obstetric Emergency Care for Adolescent Pregnancy Initial Action Plan

Place the student in a comfortable position

Assess and record the student’s physical and emotional condition, keeping the student calm

Determine if student has other health conditions that may impact the pregnancy

Obtain history, including drugs used within 24 hours - conduct initial assessment

Determine if condition is Non-urgent, Urgent or Emergent and treat accordingly

Re-evaluate student’s condition and determine if student should be:

Sent to class

Sent home and/or

Sent to healthcare provider



PREGNANCY EMERGENCY CARE PLAN


History of trauma

Vaginal bleeding, amniotic fluid present

Severe cramping or contractions > 10 mins apart

Crowning

Urge to move bowels

Pregnancy induced hypertension

Seizure

Immediate Action to Take:

Check for bleeding, mucus plug, amniotic fluid

Monitor blood pressure

Monitor pulse rate

Time uterine contractions if present

Review and follow obstetric emergencies algorithm - Page 38 of Desktop Guide for Emergency Care and Injury Response

Call parent/guardian

If student is unresponsive, or bleeding is present, call 911, parent/guardian at once

While waiting, position student safely


Is there any other action related to existing or new medical problems that would be helpful for your student in case of a medical emergency in school related to her pregnancy? __________________________________________________________________________________________________________________________________________________________________________________________

Please circle your response: (I do / do not) give my permission for the School Nurse to take the above emergency measures for my student’s

(name) ______________________________________ health and safety. NOTE: The nurse will have to call 911 for certain emergency situations to ensure the best outcomes for your student and her baby. (I do / do not) give my permission for the School Nurse to contact the healthcare provider for information relevant to her medical condition as determined appropriate for my student’s health and safety. (I do / do not) give the School Nurse my permission to share information relevant to my student’s medical status,

with specific school personnel on a “need to know” basis, if he/she determines this information is necessary to assure my student’s health and safety. PARENT/GUARDIAN SIGNATURE_____________________________________________DATE______________


HCDPBC School Health Rev 8/06 Page 1 of 2 P:\SchHlthAdmin\CarePlans\Seizure

Medical History of Student with Seizure Disorder Parent /Guardian Questionnaire

Student ________________________________________DOB________________ School Year________________

School_________________________________________Gr/Teacher/ESE_____________/______________/ Y/N

Parent/Guardian_______________________________ Phones: Home_______________Work_________________

Address____________________________________________ Cell_________________ Other ________________

Physician _________________________________________________ Phone ______________________________

Dear Parent/Guardian: School records indicate your child has a serious health condition. Please complete the following questionnaire and return it to me as soon as possible. This will help us to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Call me with any questions or concerns during school hours.

_________________________________ _____________________ ___________________ SCHOOL NURSE PHONE DATE

1. How often does your child have a seizure? _______________________________________________________ When was the last seizure? ___________________________________________________________________

2. Has your child ever been hospitalized for seizures? □ Yes □ No

If yes, when________________________________________________________________________________

3. Has your child ever had surgery to reduce seizures? □ Yes □ No

4. Please check anything that triggers seizure activity in your child: □ No medication □ Lack of sleep □ Illness or fever □ Poor nutrition □ Stress □ Strobe lights □ Menstrual cycle □ Violent movement, fighting

5. Describe usual behaviors (if any) before a seizure occurs ____________________________________________ _________________________________________________________________________________________

6. Describe your child‟s typical seizure activity. Please include usual seizure activity, duration and part(s) of body involved in the seizure _______________________________________________________________________ _________________________________________________________________________________________

7. Please list the medications your child takes for seizures – every day and as needed. Medication Route Dosage Time In School__________________________________________________________________________________ __________________________________________________________________________________ At Home __________________________________________________________________________________ __________________________________________________________________________________

Does your child show any side effects from medication? ____________________________________________ _________________________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child‟s medication or

treatments? □ Yes □ No

8. Does your child understand and participate in management of his/her seizure disorder? □ Totally responsible □ Needs reminding □ Unable/non-compliant

9. Have you ever attended a seizure education class? □Yes □ No Has your child attended a seizure education class? □ Yes □ No Are you familiar with services offered by the Epilepsy Foundation? □ Yes □ No

10. Does your child need any special considerations/accommodations related to his/her seizure disorder while in school or on a field trip? □ No □ Yes If yes, please list _______________________________________

_________________________________________________________________________________________


HCDPBC School Health Rev 8/06 Page 2 of 2 P:\SchHlthAdmin\CarePlans\Seizure



Individualized Seizure Initial Action Plan Determined by the student’s physician and based upon a number of factors.

If indicated, ease the student gently to the floor with something soft under the head

If possible, remove all furniture/equipment for student‟s safety - Do not restrict movement

Turn carefully onto side to keep airway clear – DO NOT PUT ANYTHING IN STUDENT’S MOUTH

Administer Diastat (rectal medication) if ordered by physician – have 911 called at same time

Monitor the student‟s seizure activity and record baseline LOC, characteristics and duration of seizure

When seizure is over and full consciousness returns, let student rest in lateral recumbent position

Re-evaluate student‟s condition and determine whether student should return to class, stay in health room, or be sent home and/or to their healthcare provider



LOCATION OF DIASTAT _____________________________________________________________________________

SEIZURE EMERGENCY CARE PLAN

Serious Signs and Symptoms: See Desktop Guide for Emergency Care and Injury Response : Page 41 Seizure lasting more than 5 minutes

Slow recovery, series of seizures or respiratory compromise, i.e. airway obstruction

Seizure associated with head injury, trauma, or other disorder

Postictal period longer than 10 minutes

Any change in usual seizure activity

Signs of any injury associated with seizure

No history of seizure activity or no recent seizures, if seizure history

Immediate Actions to Take: Follow emergency response orders on Physician

Authorization for Seizure Medication


Call 911



If transported, call Emergency Room with pertinent information, designee can provide student health information

Is there any other action that would be helpful for your child in case of a medical emergency in school? ______________________________________________________________________ Please circle appropriate response for each and sign. I do/ do not give the School Nurse my permission to follow the above emergency measures to assure my child‟s

health and safety.


I do/ do not give the School Nurse my permission to share medical information with specific school staff on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.

____________________________________________________ _______________________ PARENT/GUARDIAN SIGNATURE DATE _________________________________________________________________________________________________________

(Nurse Use Only) Update the initial questionnaire yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child‟s medical management. Document a brief narrative note, sign and date, followed with a case note in Welligent. Narrative Note:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

□ Transferred to: ______________________________________________________

□ Unable to make contact with parents:


HCDPBC School Rev 9/06 Page 1 of 2 P\:SchHlthAdmin\CarePlans\SeriousMedicalCondition

Medical History of Student with _____________________________ Parent /Guardian Questionnaire

Student __________________________________ DOB________________ School Year____________ School___________________________________ Gr/Teacher/ESE ___________/_____________/ Y\N Parent/Guardian____________________________Phones: Home _____________ Work____________ Address__________________________________ Cell ___________________ Other ______________ Physician_________________________________ Phone _____________________________________

Dear Parent/Guardian:

You have indicated on school records that your child has a health condition that needs to be monitored in the school setting. Please complete the following questionnaire and return it to me as soon as possible. This will help us to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Call me with any questions or concerns. Sincerely, ___________________________________________ ______________________ _____________________ SCHOOL NURSE PHONE DATE

1. Describe your child‟s medical condition. Please include any diagnosis used by your child‟s physician. ________________________________________________________________________________

_________________________________________________________________________________ 2. How long has your child had this condition? _____________________________________________ 3. Please describe any special needs your child may have during the school day and/or on a field trip.

Include any equipment, restrictions or assistance necessary. ________________________________________________________________________________

_________________________________________________________________________________

4. Is your child able to describe how he/she feels when help is needed? □ No □ Yes Describe the symptoms: ____________________________________________________________

5. Has your child ever been hospitalized for this condition? No Yes If yes, how many times and when? _______________________________________________________________________

6. Does your child attend an outpatient center on a hospital campus for specialized care? □ No □ Yes

If yes, please name the doctor and his/her specialty: ______________________________________ Has this doctor prescribed any specific treatment or care? __________________________________

7. Does anything trigger or aggravate your child‟s medical condition? □No □ Yes If yes, please

explain: __________________________________________________________________________ ________________________________________________________________________________

8. Please list the medications your child takes - everyday and as needed. Name of Medication Route Dosage Time In school________________________________________________________________________ At home ________________________________________________________________________

Do you understand the medication/treatment authorization form needed for your child‟s medications or treatments? □ Yes □ No If no, please see the school nurse.

9. Does your child understand and participate in management of his/her medical condition?

□ Totally responsible □ Needs reminding □ Unable/non-compliant

10. Is there any other information you would like us to know about your child‟s condition?

________________________________________________________________________________


HCDPBC School Rev 9/06 Page 2 of 2 P\:SchHlthAdmin\CarePlans\SeriousMedicalCondition



Serious Medical Condition Initial Action Plan

Assess and document student‟s condition, including vital signs and recent medication use relative to the student‟s normal base line

Determine whether to:

Return student to class

Call parent/guardian

Call healthcare provider

Send student home and/or

Recommend evaluation by healthcare provider


SERIOUS MEDICAL CONDITION EMERGENCY CARE PLAN Parent to describe usual:

Signs and symptoms seen in your child when health deteriorates:

General appearance Airway/breathing

Circulation

Disability:

Immediate action to take: 1. Follow emergency care protocols 2. Call 911 3. Notify parent/guardian/other designated

emergency contact 4. Notify healthcare provider 5. Notify school health room designee 6. EMS will evaluate student

7. If transported, nurse to call Emergency Room staff with nursing report, school‟s designee can provide student health information

Are there any other actions specific to your child‟s health condition that would be helpful for your child in case of a medical emergency in school? ____________________________________________________________________

______________________________________________________________________

Please circle appropriate response for each and sign below.



I do/ do not give the School Nurse my permission to share medical information with specific school personnel on a “need to know” basis, if he/she determines this information is necessary to assure my child‟s health and safety.


____________________________________________________________________________________ (Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child‟s medical management. Document a brief narrative note, sign and date, followed with case note in Welligent. Narrative Note:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

□ Student Transferred to: _____________________________________________________________________________ (School)

□ Unable to make contact with parents to discuss student‟s health condition:

Dates/times of contact attempts________________________________________________________________________________


HCDPBC School Health Rev 9/06 Page 1 of 3 P:\SchHlthAdmin\CarePlans\SickleCell

Medical History of Student with Sickle Cell Disease Parent /Guardian Questionnaire

Student _________________________________ DOB______________ School Year_______________ School__________________________________ Gr/Teacher/ESE _______/________________/ Y/N Parent/Guardian__________________________ Phones: Home _____________ Work _____________ Address_________________________________ Cell ____________________ Other ______________ Physician________________________________ Phone ______________________________________

Dear Parent/Guardian: You have indicated that your child has Sickle Cell Disease. Please complete the following

questionnaire and return it to me as soon as possible. This will help us to determine any special needs your child may have in school. Together we can help your child remain healthy and ready to learn. This medical information will become part of your child‟s confidential school health record. With your written consent, I will share this information with specific school personnel on a „need to know‟ basis only. Please keep me informed of any changes in your child‟s condition or medication. Always call me with any questions or concerns. _______________________________ __________________ ________________ Your school nurse Telephone Date

1. Was your child diagnosed at birth with the condition? □ Yes □ No

2. If not, when was your child diagnosed? ______________________________________________

3. Which type of sickle cell disease does your child have? ________________________________

4. Which hospital is treating your child for the condition? ________________________________

5. How often do you follow up at the hospital with your child? _____________________________

6. Does your child have any other health conditions, such as asthma, diabetes or any other condition? □ Yes □ No If yes, please name the condition(s) ________________________________

7. Describe your child‟s current medical condition _______________________________________

8. Which of the following symptoms does your child usually display? (please X all the boxes that apply)

□ Pain □ Fever/Infection □ Shortness of breath □ Dehydration □ Chest pain □ Congested cough □ Abdominal pain □ Skin ulcers □ Kidney problems □ Hand or foot problems Please add conditions not described in #8 above_________________________________________ ________________________________________________________________________________

9. Is your child able to describe how he/she is feeling when help is needed? □ Yes □ No

________________________________________________________________________________ 10. What is your child‟s present management routine at home (include all important information including

daily fluid requirements)? ________________________________________________________________________________ ________________________________________________________________________________

________________________________________________________________________________



Student_________________________________ DOB___________________ Date_____________

11. Please list the medications your child takes for sickle cell disease - everyday and as needed:

Name of Medication Route Dose Frequency In school_________________________________________________________________________ _________________________________________________________________________ At home ________________________________________________________________________

_________________________________________________________________________ Do you understand the medication/treatment authorization form needed for your child‟s medications or treatments? □ Yes □ No If no, please see the school nurse.

12. Does your child have any side effects to any of their medications? ____________________________

________________________________________________________________________________ 13. Does your child need any special considerations/accommodations related to his/her condition while

on a field trip? No Yes If yes, please list:__________________________________________

14. Does your child understand and participate in management of his/her medical condition?

Totally responsible May need reminding Will always need reminding

15. Is there any other information you would like us to know about your child‟s condition? ________________________________________________________________________________ ________________________________________________________________________________

The school nurse will take the following action if your child has a medical problem


Sickle Cell Disease Initial Action Plan

Observation and assessment of student and minimal effects of sickling

Avoid using ice packs for local bruises/injuries – could cause sickling

Have student rest in a comfortable sitting position and obtain history

Assess and record student‟s physical status, including vital signs

Assess for signs of sickle cell crisis

Administer treatment and medications as ordered

Re-evaluate student‟s condition and determine if student should be: o Allowed to rest o Sent back to class o Sent home o Sent to healthcare provider





SICKLE CELL DISEASE EMERGENCY CARE PLAN


Chest syndrome: o Respiratory distress o Dyspnea or tachypnea o Severe chest pain o Retractions o Very congested cough o Fever of 102° F or higher (check

physician‟s order)

Neurological o Seizures o Jerking or twitching of the face o Abnormal behavior o Inability to move an arm or a leg o Changes in vision o Unsteady walk or stagger o Weakness in hands or legs o Altered mentation (confused and

unable to think clearly, etc.)

Systemic: o Severe pain – sharp and localized o Severe vomiting/diarrhea o Temperature greater than 101.5° F o Side effects of medication o Excessive bruising, joint pain, swelling

Immediate Action: Follow emergency response orders on

Physician Authorization Form

Call 911

Notify parent/guardian and health room designee


If transported, nurse to call Emergency Room with specific observations and nursing report; if a designee, relevant student health information

should be provided See Desktop Guide to Emergency Care and Injury Response – Page 43

Are there any other actions that would be helpful for your child in case of a medical emergency in school? ____________________________________________________________________________________ ____________________________________________________________________________________ Please circle appropriate response for each and sign below.



I do/ do not give the School Nurse my permission to share medical information with specific school personnel on a “need to know” basis, if he/she determines this information is necessary to assure my

child‟s health and safety.


______________________________________________________________________ (Nurse Use Only) Update the initial questionnaire, yearly with the parent. New parent questionnaire required only when student transfers to new school or change in child‟s medical management. Document findings in a brief narrative note, sign, and date, followed with case note in Welligent. Narrative Note:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

□ Transferred to: _______________________________________________________________ (School)

□ Unable to make contact with parents to discuss student‟s health condition

□ Dates/times of contact attempts_________________________________________________________

Documents

Palm Beach County School Health Medical History of Student