Medical Directives

  • 17 Dec 2017 8:32 AM
    Reply # 5631352 on 5612198
    Meg Jenkins wrote:

    In Gilford, we incorporate it into our Annual Health Update. I will try to attach it.


    Thanks Meg, but my question was in regard to medical directives, or standing orders signed by MD.

    Last modified: 17 Dec 2017 8:33 AM | Anonymous
  • 04 Dec 2017 10:52 AM
    Reply # 5612198 on 5607997

    In Gilford, we incorporate it into our Annual Health Update. I will try to attach it.


                 GILFORD ELEMENTARY                                                             GILFORD MIDDLE                                                                      GILFORD HIGH

                 Jenn McGonagle RN                                                               Beth Haddock RN                                                                         Meg Jenkins RN  


    Please check if you need info regarding

    NH Healthy kids for insurance _________

    Students Name _________________________________DOB _____Grade_____________

    Physician/PCP_________________________________________ Tel______________________

    Health Information

    In an effort to protect your child’s privacy, no information will be shared with teachers, and any appropriate staff members including bus drivers unless you agree to it in writing.  Please review, sign and return the following information to the School Nurse.

                    ***This includes contacting your child’s primary care provider for Immunization records and Status/Copy of Physicals needed for sports participation***

    Allergies _____         Asthma _____      Attention Problems_____   Bee Sting Reactor _____    Diabetes______   Frequent Nosebleeds _____      Headaches ______

    Medication Allergies _______________ Rash/ hives ___     Seizures _____     Mobility Problems _____        Frequent stomach aches ______      Migraines _____      

    Glasses/contacts ____ Hearing _____     Mononucleosis __     other ___________________________________

    Any head injury? Concussion? ____________ knocked out? _____________ Date(s) _____ _____ ______

    Were you treated by a medical professional? ___________ Dates______ _______ ________

    Have you had one or more serious sprain or strain of a joint? Knee_________ Ankle________ other______ Date(s) ________ ________

    History of sudden cardiac death in immediate family member? ______ History of fainting during exercise? _____ fainting due to unexplained causes? ____


    ►Parent /Guardian Signature_______________________________ Date _______



    Students shall not carry any medication on them. The one exception is a prescribed inhaler for asthma or an Epi-pen for severe allergic reaction or diabetic supplies

    ·         If your child has either of the above prescribed, contact School Nurse so you may get the correct form for the physician and you to fill out.

    ·         If your child needs a medication while at school, please see School Nurse for the appropriate form. Only medication that is in its original container will be accepted when dropped off by a parent or other adult.

    Please indicate which over the counter medication your child may have in the course of the day. If there is something not listed here and you wish it to be available for your child, please bring it to the School Nurse in an original container.

    Please circle Yes or No:

    Acetaminophen yes/no         Antacids (Tums) yes/no   Aleve Yes/No                                      Sunscreen yes/no                Bug Spray /no   

    Ibuprofen (Advil) yes/no     Midol yes/no                      Diphenhydramine (Benadryl) yes/no     Decongestant   yes/no         Gum Soother (Oragel)    yes/no   


    ►Parent/Guardian Signature ____________________________ Date ______


    Emergency Treatment

    I understand that in case of illness or injury I will be notified as soon as possible and I give my permission for emergency treatment or surgery as recommended by physician.

    ►Parent/Guardian Signature ________________________________       Date ______

    Last modified: 04 Dec 2017 10:54 AM | Anonymous
  • 30 Nov 2017 1:40 PM
    Message # 5607997

    Does everyone have annually signed medical directives? (standing orders). 

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