and print one packet

 Shady Side Academy Family Information Update 2016-­2017 Medical and Athletic Forms Grades PK-­5 Please complete one packet of forms per child. Mail completed forms by August 1, 2016 to: Julianne Killian, School Nurse Shady Side Academy Junior School 400 S. Braddock Avenue Pittsburgh, PA 15221 Each page in the packet is marked as Required, Optional or Read-­‐‑Only. Required forms must be received in order for students to begin school in the fall. Optional forms give nurses permission to administer over-­‐‑
the-­‐‑counter or prescription medications at school. Read-­‐‑Only pages are for your files. If you have questions about the medical forms, please contact Junior School Nurse Julianne Killian at 412-­‐‑
473-­‐‑4189 or [email protected]. The following forms are included in this packet: c Student Health History – Required Completed by the parent and includes required health information. c Physical Examination Form – Required Must be completed by a physician, and the physical must have taken place after August 1, 2015. c Immunization Form – Required Pennsylvania state law requires that all students have a completed immunization record on file. A doctor’s printout will be accepted, or a physician may complete the enclosed form. c Dental Form – Required K and 3 ONLY Must be completed by a dentist and is required for kindergarten and third grade students only. c Transportation Form – Required Completed by the parent and collects busing, car pool and other transportation information. c Over-­‐‑the-­‐‑Counter Medication Authorization Form – Optional Completed by the parent if you wish to authorize SSA health personnel to administer over-­‐‑the-­‐‑
counter medications to your child as needed at school. c Medication Authorization Form – Optional Completed by the parent and a physician and necessary for any student who must bring prescription medication to school, such as albuterol or an EpiPen. c Medication Policy – Read-­‐‑Only Please read and keep a copy of this important school policy at home. Student Physical Immunization Dental Over-­‐‑the-­‐‑
Medication Transportation Health Exam Form Form Counter Authorization Form History Form Medication Form Form ✔ ✔ ✔ ✔ PK Optional Optional ✔ ✔ ✔ ✔ ✔ K Optional Optional ✔ ✔ ✔ ✔ 1 Optional Optional 2 3 4 5 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Optional Optional Optional Optional Optional Optional Optional Optional ✔ ✔ ✔ ✔ Student’s Name
Age
Grade
SECTION 5: HEALTH HISTORY
Explain “Yes” answers at the bottom of this form.
Circle questions you don’t know the answers to.
Yes
Neck
Shoulder
Upper
back
Lower
back
Hip
20.
21.
Upper
arm
Thigh
Elbow
Forearm
Knee
Calf/shin
Have you ever had a stress fracture?
Have you been told that you have or have
you had an x-ray for atlantoaxial (neck)
instability?
22.
Do you regularly use a brace or assistive
device?
#’s
No
23.
Has a doctor ever denied or restricted your
participation in sport(s) for any reason?
2.
Do you have an ongoing medical condition
(like asthma or diabetes)?
3.
Are you currently taking any prescription or
nonprescription (over-the-counter) medicines
or pills?
4.
Do you have allergies to medicines,
pollens, foods, or stinging insects?
5.
Have you ever passed out or nearly
passed out DURING exercise?
6.
Have you ever passed out or nearly
passed out AFTER exercise?
7.
Have you ever had discomfort, pain, or
pressure in your chest during exercise?
8.
Does your heart race or skip beats during
exercise?
9.
Has a doctor ever told you that you have
(check all that apply):
High blood pressure
Heart murmur
High cholesterol
Heart infection
10.
Has a doctor ever ordered a test for your
heart? (for example ECG, echocardiogram)
11.
Has anyone in your family died for no
apparent reason?
12.
Does anyone in your family have a heart
problem?
13.
Has any family member or relative been
disabled from heart disease or died of heart
problems or sudden death before age 50?
14.
Does anyone in your family have Marfan
syndrome?
15.
Have you ever spent the night in a
hospital?
16.
Have you ever had surgery?
17.
Have you ever had an injury, like a sprain,
muscle, or ligament tear, or tendonitis, which
caused you to miss a Practice or Contest?
If yes, circle affected area below:
18.
Have you had any broken or fractured
bones or dislocated joints? If yes, circle
below:
19.
Have you had a bone or joint injury that
required x-rays, MRI, CT, surgery, injections,
rehabilitation, physical therapy, a brace, a
cast, or crutches? If yes, circle below:
Head
Yes
No
1.
Hand/
Fingers
Ankle
Chest
Foot/
Toes
Has a doctor ever told you that you have
asthma or allergies?
24.
Do you cough, wheeze, or have difficulty
breathing DURING or AFTER exercise?
25.
Is there anyone in your family who has
asthma?
26.
Have you ever used an inhaler or taken
asthma medicine?
27.
Were you born without or are your missing
a kidney, an eye, a testicle, or any other
organ?
28.
Have you had infectious mononucleosis
(mono) within the last month?
29.
Do you have any rashes, pressure sores,
or other skin problems?
30.
Have you ever had a herpes skin
infection?
CONCUSSION OR TRAUMATIC BRAIN INJURY
31.
Have you ever had a concussion (i.e. bell
rung, ding, head rush) or traumatic brain
injury?
32.
Have you been hit in the head and been
confused or lost your memory?
33.
Do you experience dizziness and/or
headaches with exercise?
34.
Have you ever had a seizure?
35.
Have you ever had numbness, tingling, or
weakness in your arms or legs after being hit
or falling?
36.
Have you ever been unable to move your
arms or legs after being hit or falling?
37.
When exercising in the heat, do you have
severe muscle cramps or become ill?
38.
Has a doctor told you that you or someone
in your family has sickle cell trait or sickle cell
disease?
39.
Have you had any problems with your
eyes or vision?
40.
Do you wear glasses or contact lenses?
41.
Do you wear protective eyewear, such as
goggles or a face shield?
42.
Are you unhappy with your weight?
43.
Are you trying to gain or lose weight?
44.
Has anyone recommended you change
your weight or eating habits?
45.
Do you limit or carefully control what you
eat?
46.
Do you have any concerns that you would
like to discuss with a doctor?
FEMALES ONLY
47.
Have you ever had a menstrual period?
48.
How old were you when you had your first
menstrual period?
49.
How many periods have you had in the
last 12 months?
50.
Are you pregnant?
Explain “Yes” answers here:
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Student’s Signature _________________________________________________________________________Date____/____/_____
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Parent’s/Guardian’s Signature _________________________________________________________________Date____/____/_____
Shady Side Academy
Yearly Physical Report
Must be completed by the Authorized Medical Examiner (AME) performing the herein named student’s comprehensive physical evaluation and turned
in to the student’s school by Aug. 1. There should be a definite statement regarding each item, representing the result of a thorough medical
examination on the day the form is dated and signed. THIS EXAM IS REQUIRED EACH YEAR for all students.
Students in grades PK-5 – this physical must be dated after Aug. 1 of the previous year.
This information may be shared with Academy personnel on a need to know basis.
Student’s Name____________________________________________________ Birth Date_________________ Grade___________ Sex:
M
F
Height__________ Weight___________ % Body Fat (optional) __________BP______________________ Resting Pulse(RP)____________________
If either the BP or RP is above the following levels, further examination by the student’s primary care physician is recommended. Age 10-12:
BP <126/82, RP<104; Age 13-15: BP<136/86, RP <100; Age 16-25: BP ,142/92, RP <96
Vision: R 20/_______
L 20/_______ Corrected? YES
MEDICAL
NO
Pupils: Equal______ Unequal______ Hearing: R __________db
NORMAL
ABNORMAL FINDINGS
NORMAL
ABNORMAL FINDINGS
L __________db
Appearance
Eyes/Ears/Nose/Throat
Hearing
Lymph Nodes
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Neuropsychiatric/Learning Disability
Metabolic/Endocrine
Skin
Scoliosis
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Wrist/ Hand/ Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
******IMMUNIZATIONS: Please attach immunization record******
ANY KNOWN ALLERGIES?_____________________________________________ Is the student currently taking any medications?
Is the student now under treatment for any medical or emotional condition?
YES
NO
YES NO
(please explain any YES answers on back of sheet)
RECOMMENDATION(S)/REFERRALS___________________________________________________________________________________________
AME’s Name____ ____________________________________________ Physical Date (please see opening paragraph) _________________________
AME’s Signature _________________________________________ MD, DO, PAC,CRNP, or SNP (circle one) License #__________________________
Address_______________________________________________________________________ Phone # ______________________________________
REQUIRED PK-­‐5 Shady Side Academy
Immunization Form
Name________________________Grade_______Date of Birth___________
Dear Doctor,
In order to assist the school in complying with the Pennsylvania State Law requiring immunization
of children entering school, we are requesting that this form be completed and returned to the
health office as soon as possible. We will also accept a doctor’s printout of a student’s
immunization record.
IMMUNIZATIONS
GIVE ALL DATES for new students
Returning Students- Updates only
Diptheria and Tetanus (DTaP, DTP, TD or
DT) 4 doses
Tdap on or after the 10th birthday
HIB
Meningitis (Menactra)
MMR - 2 doses
Polio (OPV or IPV) 3 doses
Hepatitis B – 3 doses
Varicella – 2 doses or MD documented
disease
TB test
Hepatitis A
______________________________________________ ________________
Physician Signature
Date REQUIRED K AND 3 ONLY Shady Side Academy Dental Form This Form is only required for students in grades K, 3 and 7, and must be completed by the student’s dentist. FIRST NAME LAST NAME MIDDLE INITIAL BIRTH DATE SEX GRADE (Please circle) K 3 7 DATE OF LAST EXAM At that time, were all dental corrections made? If the above answer was NO-­‐please fill in the following: Primary teeth _____fillings _____extractions Permanent teeth _____fillings _____extractions Diseases of the supporting tissues _____yes _____no Gross malocclusion producing a facial deformity or interfering with function _____yes _____no Cleft lip or palate _____yes _____no Other congenital malformations _____yes _____no Prosthetic replacements for lost or missing teeth _____ yes _____no If the answer to any of the above are yes, please explain ________________ SIGNATURE of DENTIST DATE PHONE Shady Side Academy Junior School
Transportation Form
Transportation information must be on file in the office. If your child's mode of transportation changes during the school year, you must notify the office immediately. Shady Side Academy does not provide busing. If you live within a 10-­‐mile radius of the Junior School, the school district in which you reside is responsible for providing busing for your child. City of Pittsburgh residents living more than 1.5 miles from the Junior School (measured via the nearest public street or road), qualify for transportation by Pittsburgh Public Schools. SSA will contact the public school district in which you reside, and the school district will notify you of your bus schedule after the middle of August. All busing problems must be directed to the school district in which you reside—not Shady Side Academy Junior School. Daily Transportation Student’s Name: _________________________________________________ Grade:____________ ______ My child will take______________________________________________ bus transportation. (Name of school district, i.e. Fox Chapel, Pittsburgh, Gateway, Plum, etc.) ______ My child will walk to the Junior School (children are not permitted to walk alone). ______ I will drive my child to and from the Junior School each day. ______ My child will participate in a carpool to and from the Junior School each day. Driver(s): _____________________________________________________________________________________ Students: _____________________________________________________________________________________ The following individuals are authorized to pick up my child or children: * Please indicate with an asterisk who should be contacted first. Name Relationship Home Phone Mobile Phone Emergency or Snow Day Early Dismissal Permission When there is an emergency dismissal, we will send children home as their school district buses arrive, except for those who are scheduled for After School Explorers on that particular day and those who check the box below. Students not taking a bus must be picked up as soon as possible. Please call the Junior School at 412-­‐473-­‐4400 so that we have some idea when to expect you at school. If Shady Side Academy must dismiss school early due to an emergency situation, I request that my child not take his/her regular bus home. I understand that I will be responsible for calling the Junior School and arranging for his/her transportation as soon as possible. Parent’s Name: __________________________________________________ Phone: ____________ (please print) Parent’s Signature: _______________________________________________ Date: ____________ Shady Side Academy
Over-the-Counter Medication Authorization
Below is a list of over-­‐the-­‐counter medications that Shady Side Academy currently keeps on hand to be given by licensed personnel only. Generic equivalents may be used. PLEASE CHECK (✓) THOSE WHICH YOU ALLOW YOUR CHILD TO BE GIVEN: ADVIL THROAT LOZANGES HYDROCORTISONE CREAM TYLENOL BENADRYL (emergency only) ANTIBIOTIC OINTMENT SUDAFED ANTIDIARRHEAL COUGH MEDICINE ANTACID ****Please note that no medications will be given to your child unless it is checked above and the consent signed. I consent to, and authorize the health office personnel of Shady Side Academy to give my child the over-­‐
the-­‐counter medications checked above. I understand that my consent and authorization is revocable in writing at any time. I release Shady Side Academy and all of its employees from all liability my child may suffer as a result of this request. Student Name: ______________________________________________ Grade: _____________ X ______________________________________________________________ _____________________ SIGNATURE OF PARENT/GUARDIAN DATE This consent will be in effect until the end of the current school year.
Shady Side Academy
Authorization for Medications to be Taken During School Hours
Please complete this form if your child must take medication(s) during the school day. This
form should be signed by your child’s physician and returned to the nurse’s office at your
child’s school.
Student ______________________________________________________Grade_______________
Physician’s Name _______________________________Physician’s Phone____________________
PRESCRIPTION MEDICATION MUST BE IN A CURRENT PHARMACEUTICAL CONTAINER WITH A PRESCRIPTION
LABEL ATTACHED AND BROUGHT TO THE SCHOOL NURSE WITH THIS COMPLETED FORM. OVER-THECOUNTER MEDICATIONS MUST BE IN THEIR ORIGINAL CONTAINER, LABELED WITH THE CHILD’S NAME AND
DOSAGE REQUIRED.
Check one of the following: (Please read carefully and see medication policy for more information).
This option must be checked for all medications except inhalers and epipens
___ I give the School Nurse permission to administer this medication to my child as described below.
This option may be used for inhalers and epipens
___I give my child permission to keep this medication with him/her throughout the school day and self
medicate as described below.
I hereby indemnify Shady Side Academy or any of its personnel, employees, or agents from any claim,
demand, cause of action, or liability asserted against them arising out of the students taking, or failing to take,
the medication in the dosage or at the time prescribed below. I understand that the permission granted will be
terminated in accordance with the physician’s directive, or automatically at the close of the school year.
______________________
Date
______________________________________________________
Signature of Parent/Guardian
Name of Medication ________________________________________________________________
Dosage__________________________________________________________________________
Reason for the Medication ___________________________________________________________
If medication is to be given daily, at what time ____________________________________________
If medication is to be given PRN, describe indications ______________________________________
List significant side effects ___________________________________________________________
Length of time medication is to be given ________________________________________________
Other Information __________________________________________________________________
____________________
Date
__________________________________________________
Signature of Physician
Shady Side Academy Medication Policy READ ONLY Shady Side Academy has closely followed the Pennsylvania Department of Health’s “Guidelines for Pennsylvania Schools for the Administration of Medications and Emergency Care” in developing the Academy’s policy concerning the administration of medications. The purpose of these guidelines is to assist Pennsylvania schools in ensuring the safe administration of medications to students. Shady Side Academy acknowledges and adheres to the Department of Health’s guidelines in that the Academy nurses cannot lawfully delegate medication administration to teachers or administrative personnel. This current policy replaces all previous documents regarding administration of medications at Shady Side Academy. Taking medication of any kind involves some risk of complications. Although every effort should be made for children to take their medications at home under the supervision of their parents, the Academy understands that for some children it might be necessary to take medications while in school. If medication must be taken during school hours, it is important for parents and students to follow the appropriate procedures listed in this document. Introduction to Medication Policy If your child requires medication (prescription or over the counter) during the school day or after school hours (for boarders), please contact school nurse and refer to the guidelines below. Additionally, it is the parent’s responsibility to inform/update the nurse of any medications, allergies, and/or health concerns to keep this information as current as possible in case of an emergency. Prescription Medications All medications must be brought to school by a parent/guardian in the prescription-­‐labeled container, which must remain at school in a locked cabinet. If necessary, parents should request a duplicate container from the pharmacy. Students should not transport medications to school. Please indicate if the medication must be refrigerated. If a student has been ordered to take a new medication the first dose must be given at home by the parent/guardian to ensure that the student does not have a negative reaction to the medication. All controlled prescription medication, will be counted by the nurse and parent/guardian when it is brought into the Nurse’s Office. The amount will be documented on the medication record. This documentation and counting procedure should also be done when the parent/guardian refills the medication or takes medications home at the end of the year. Written instructions from a physician with the student’s name, medication, diagnosis, dosage, length of time to be given, side effects, termination date AND physician signature is required for all medications. Parents must also sign the Medication Authorization form. Medication Authorization Forms are available on the parent portal and through the school nurse. It is the student’s responsibility to come to the Nurse’s Office to take the medication. All medication should be picked up by an adult at the end of the school year. Medications that are not picked up within one week of the end of the school year will be disposed of by the school nurse. Any used syringes or other bio-­‐hazardous materials must be disposed of in school designated bio-­‐hazardous receptacles (located in the Nurse’s Office and Training Room). Non-­‐Prescription/Over-­‐the-­‐Counter Medication At the beginning of the year, parents may choose to fill out the Over-­‐the-­‐Counter Medication permission form to allow the school nurse to give specific over-­‐the-­‐counter medications throughout the school year. Students are not permitted to carry any over-­‐the-­‐counter medications or supplements. All over-­‐the-­‐counter medications should be transported to the Nurse’s Office by the parent/guardian. Shady Side Academy has standing physician orders that allow the school nurses to give certain over-­‐the-­‐counter medications such as Tylenol, ibuprofen and throat lozenges. The OTC Medication Authorization Form must be completed by the parent/guardian and physician for over-­‐the-­‐counter medications that are not covered by the standing physician orders. If you have a question about a specific medication, please contact the school nurse. Inhalers Students are permitted to carry inhalers with them during school and from school as long as the Medication Authorization Form is signed both by a physician and parent/guardian and the physician permits the student to carry the inhaler. The school nurse will ensure that the student is competent in properly using the inhaler through a student demonstration. The student should immediately notify the nurse following each inhaler use. Epi-­‐Pens Students are permitted to carry an EpiPen with them throughout the day provided they have a signed Medication Authorization Form on file in the Nurse’s Office. If a student is unable to self-­‐administer the EpiPen, it may be given by a designated, trained individual. Safe Medication Administration and Preparation Verify the Five Rights of Medication Administration: 1.
2.
3.
4.
5.
Right Student Right Medication Right Dose Right Route Right time Medications should never be left unsupervised. Student should also verify that the medication label is correct. The nurse may refuse to administer medication based on her assessment and nursing judgment if the medication has the potential to be harmful or inappropriate. In these rare cases, the nurse will notify the parent/guardian immediately and explain the reason for refusal. Residential Life Students Please follow the day student policy. Contact the Senior School nurse if your child will require any medication (prescription or over the counter) and follow the above guidelines. Field Trip Policy Due to changes in the Pennsylvania Medication Administration Guidelines for Schools, non-­‐licensed personnel such as teachers and coaches are not permitted to administer medications if they need to be taken during school trips. On trips where students require medication administration, there are several alternatives: 1. You may choose to make your own arrangements to give your child his/her medication. 2. If possible, you can consult with your physician about the possibility of having your child not take the medication while on the trip. 3. The student may self-­‐administer medications (if the student follows the guidelines below.) 4. If a student is unable to follow the above three options and will not be able to attend the trip for medication reasons, please contact the school nurse to discuss options. You must follow these guidelines for a student to self-­‐administer: 1.
2.
3.
4.
5.
6.
Please sign the parent portion of the form giving permission for your child to self-­‐ administer medications (speak with school nurse for this form). The physician needs to specify that your child is capable of self-­‐administering medication by initialing the appropriate box on the form. The physician needs to write a prescription only for the specific amount of medication needed for the trip. The parents are responsible for getting the prescription filled. Medications must be in a pharmacy bottle, properly labeled for ONLY the medication that is required for the trip. If desired, one extra pill may be included just in case one is dropped, etc. The parent or guardian needs to deliver the medication to the responsible adult/coach/chaperone and educate the adult about the medication. Please make sure to describe the signs and symptoms of any possible side effects. The school nurse will not be involved in this process. Failure to follow the above guidelines will result in the student’s inability to participate. Medications may not be added/delivered the day of the trip. Please indicate to the trip leader ASAP if your child will need to take a medication during this trip so that the necessary arrangements can be made. All medications being taken during a school event of school hours must be accompanied by a physician’s order. Prescription medication must be properly labeled by a registered pharmacist and brought to school in its original labeled bottle.