Microsoft word - health questionnaire _2_.doc

IMPORTANT HEALTH GUIDELINES: PARENTS PLEASE READ.
HEALTH INFORMATION

Attached is the Beth Tfiloh Health Questionnaire requesting information concerning your child’s medical,
social and emotional history. This information, though sensitive, will enable us to understand and better
care for you child throughout the school day. We encourage you to share as much information as
possible, including all medications taken at home prior to school. ALL OF THE INFORMATION ON
THESE FORMS WILL BE KEPT IN STRICT CONFIDENCE.

Guidelines used for giving proper health care to your child are based on policies of the Baltimore County
Health Department and are as follows:
1.
A child with a temperature of 100.0 degrees or above is not permitted to be in school. The child
must have a normal temperature for 24 hours (without Tylenol or Motrin/Advil) before returning
to school.
Any child with a communicable disease is not permitted in school. However, head lice is
addressed individually by the school nurse. Once it is determined by the nurse that the family is
treating their case thoroughly, the child will be permitted to attend school, with their hair covered
and/or pulled back. The nurse will monitor the student until they are completely free of nits.
The following non-prescription medications will be available in an effort to relieve minor discomforts which impede student learning and prevent full participation in classroom activities: Acetaminophen (Tylenol), Ibuprofen (Motrin or Advil), anti-itch ointment, hydrocortisone, bacitracin, and tums. A CONSENT FORM MUST BE COMPLETED AND SIGNED BEFORE ANY
MEDICATIONS WILL BE ADMINISTERED!! (See the Beth Tfiloh Health Questionnaire.)
All medications to be administered at school, prescription and over-the-counter, MUST be
accompanied by a written order from your health care provider. A parent must bring the
medication to school in the original container. The order and medication must include name,
date, dosage, instructions and doctor’s name. If your child starts a new medication, or the current
dosage is adjusted, please notify the school immediately.
NO STUDENT WILL BE ALLOWED TO CARRY AND SELF-ADMINISTER
MEDICATION. Please notify the nurse of special circumstances authorized by a
physician.
Immunizations must be current prior to attending school. Note: All kindergarteners must have had
5 DPT, 4 polio, 2 MMR, and 3 hepatitis B vaccines. Documentation of varicella (chicken pox)
vaccination or history of the disease must be included. Students new to the school or those
entering Preschool, Gan Aleph, Kindergarten, 5th grade and 9th grade will need a Baltimore
County Health Inventory form, Immunization certificate and physical exam completed by their
health care provider. Be sure that both Part I (Parents) and Part II (health care provider) are
complete. ALL students attending Beth Tfiloh Dahan Community School must complete the Beth
Tfiloh Health Questionnaire every year. BALTIMORE COUNTY LAW MANDATES THAT
ALL FORMS MUST BE TURNED IN ON OR BEFORE THE FIRST DAY OF SCHOOL.
If there is any information about your child that you would like to discuss with our health team, please feel free to call or send a note with your completed forms. Thank you for your time; we appreciate working with you so that we may provide the best possible care for your child. THE BETH TFILOH HEALTH & WELLNESS TEAMMiddle & High School PreSchool & Lower School410-484-5073 TO BE COMPLETED FOR ALL STUDENTS BY PARENTS/GUARDIANS
2009-2010 Annual Medical Statement
BETH TFILOH HEALTH QUESTIONNAIRE
STUDENT’S NAME:_____________________________________ ENTERING GRADE:______________

MEDICAL HISTORY:
Does your child have a history of any of the following? Please circle all that apply and explain
__________________________________________________ o Expected reaction __________________________________________________ o Treatment ___________________________________________________ * Reminder: All meds that your child may need at school must be provided and Y N Inhaler/Nebulizer used at school: ______
Y N _________________________________
Y N _________________________________
• Fainting Y N _________________________________
Y N _________________________________
Y N Medication used:___________________
Y N _________________________________
Y N _________________________________
condition Y N _________________________________
Y N _________________________________
Y N _________________________________
Y N _________________________________
• Serious injury, illness, or hospitalization Y N _________________________________
Y N _________________________________
• Weigh fluctuations/eating disorder/special diet Y N ___________________________
Y N _________________________________
Medication or treatment taken at home. (Dosage, time, and purpose) ____________________ ___________________________________________________________________________ (For example: Ritalin 10 mg 7AM – ADHD) Medication or treatment that may be needed by your child at school _____________________ ____________________________________________________________________________ Date of last Tetanus Vaccine:_____________ Any vaccines received within the last year: _________________________________________ BETH TFILOH HEALTH QUESTIONNAIRE CONTINUED:

SOCIAL/EMOTIONAL
DEVELOPMENT:
Does your child have a history of any of the following? Please circle all that apply and provide a brief explanation in the space provided • Aggressive behavior/Anger Management _________________________________
• Death/Illness of close family member Y N _________________________________
_________________________________
frustrated Y N
_________________________________
_________________________________
• Recent move or other significant change Y N _________________________________
_________________________________
_________________________________
_________________________________
Y N _________________________________
_________________________________

Is your child receiving mental health support? Y N With whom? ___________________
Does your child receive speech, occupational, or physical therapy?
If not, do you feel your child would benefit from the above?
____________________________________________________________________
Is there any additional information regarding your child that you would like to share with the
school? ____________________________________________________________________
____________________________________________________________________________
Doctor’s Name ______________________________Phone#___________________________ Dentist’s Name _____________________________Phone# ___________________________ I hereby give permission for my child ______________________________to receive any medication listed below on this form as deemed necessary by the School Nurse. I have checked those medications I wish to be made available to my child. I understand that generic equivalent medications will be used in place of more expensive brand-name items. Please check any medications you wish to be made available to your child: For (like Advil, Motrin)
… I do not want any medication given to my child in school.
_____________________________________________________ ______________
Signature
Guardian

Home Phone _________________________ Work/Emergency Phone ___________________________________

Source: http://www.bethtfiloh.com/ftpimages/230/misc/misc_66151.pdf