Nottingham.k12.nh.us

Child Health Information Nottingham School

Child's Name: _______________________________________ Date of Birth: ___________________ Grade: ___________
Please note that the information on this form is documented on your child’s school health record and
the school nurse will share this information with the appropriate school staff as needed.

1. Does your child have allergies?
______No ______ Yes
(IF YES: What? Please check below and note treatment.)
____Food _____________________________________________________________________________________
____Bee/stinging insects________________________________________________________________________
____Medication ________________________________________________________________________________
____Environmental _____________________________________________________________________________
____Other ____________________________________________________________________________________
2. Does your child take any medicine on a regular, ongoing basis? ______ No ______ Yes
Name of Medication
Reason for Taking
Special Instructions for

3. Does your child have any issues with vision and/or hearing or do you have any concerns? ______No ______ Yes
(IF YES: please check below and describe.) _____ Vision (for example, wears glasses for reading) _________________________________________
_____ Hearing (for example, wears hearing aid) _________________________________________

4. In the past year, has your child had any serious illness or injury?
______No ______Yes
(IF YES: What? Any special instructions or considerations for school?) ____________________________________________________________________________________________
5. a. Does your child have an ongoing health condition that may affect him or her at school?
______ No ______ Yes
(IF YES: What? Please circle: asthma, diabetes, serious allergy, epilepsy, CF, cancer, heart condition, or other.) ____________________________________________________________________________________________ b. Does this health condition affect your child's learning or participation in activities at school? ______ No ______Yes
(for example, fatigue; ability to focus, frequent absences.) (IF YES: How?)________________________________________________________________________________
6. Does your child have health insurance? ______ No ______Yes
7. Name of Childs Physician: __________________________________________Phone:__________________________ 8. Name of Child’s Dentist: ___________________________________________Phone:__________________________ Consent: I, the parent/guardian of the above named child consent to communication and exchange of health
information between the school nurse and my child’s physician and/or dentist regarding immunizations, physical
exams, medications and current health status. ______No _____Yes

Should a serious illness or accident occur and school personnel are unable to contact parent(s) or guardian(s),
permission is granted for emergency medical care to be given as necessary including transport to the nearest hospital.
______No _____Yes

Parent / Guardian Signature: _____________________________________ Date: ______________________

Parental Consent for the Administration of
Non-Prescription Medication
Child's Name: _______________________________________ Date of Birth: ____________ Grade: ____________

Medication Allergies or Sensitivities: _________________________________________________________


I give my permission for my child to receive medication list below on this form as deemed necessary by the
School Nurse or School Staff as delegated by the Principal. I understand that the generic equivalent
medication may be used. The dose of medication will be as listed on the medication label according to age
and/or weight. If your physician has requested a dose above or below this amount, please note the dose on
this form. The school nurse does have a supply of these medications.
Please check which medications you give permission for your child to receive during the school day.

_____Acetaminophen- non-aspirin pain reliever/fever reducer (“Tylenol”)

_____Ibuprofen- pain reliever/fever reducer (“Motrin”)

_____ Diphenhydramine- (“Benadryl”)

_____Tums

_____cough drops

_____antibiotic ointment- for minor wounds, abrasions

_____burn ointment/cream

_____anti-itch sprays or creams- for rashes, bug bites, minor skin irritations

_____topical oral pain reliever- (“Orajel”)

_____Epi-Pen- used in an emergency allergic reaction only

_____I do not want my child to receive any medication while at school.


Parent / Guardian Signature: _____________________________________Date:______________________

Source: http://www.nottingham.k12.nh.us/images/ChildHealthInformation2012-2013.pdf