Lipscomb Academy Middle/High School Health Form
Dear Parent: In order for your child to be evaluated by the school nurse, should she/he become ill or experience some other type of health concern, your permission is required. By signing below, you have given the school permission to assist your child medically.
Student’s name:_________________________________________________ Grade____________
I give the school nurse permission to administer:
Yes___ No___ Acetaminophen (Tylenol) 160-650 mg – based on age/wt. (Given for pain, headache, fever)
Yes___ No___ Ibuprofen (Motrin, etc.)
100-400 mg – based on age/wt. (Given for pain, headache, fever)
Yes___ No___ Pamprin,Midol 1-2 caplets – based on wt./severity of pain (menstrual cramps)
Yes___ No___ Antacid tablets (Tums, etc)1-2 500mg tablets (for stomachache, indigestion)
Yes___ No___ Benadryl liquid or tablet 12.5 – 50mg (
1 or 2 (for coughing, sore throat, nasal congestion)
Yes___ No___ Benadryl cream 1%,spray 2% (for itching due to insect bites and minor skin irritation)
Yes___ No___ Caladryl/Calamine lotion (for itching due to poison ivy rash or minor skin irritation)
Clinic use only
Yes___ No___ Hydrocortisone cream 1% (for itching due to minor skin irritation)
Yes___ No___ Aloe gel (for pain of minor burns or sunburn) May contain Lidocaine HCL Yes___ No___ Insect bite swab contains Benzocaine and Menthol –for pain - 1 swab per sting/bite Yes___ No___ Orajel (for gum pain, canker sores) Any of the medications listed above may be generic brand. Effective _______________ until ___________________ ______________________________________Date____________ FIRST DAY OF SCHOOL LAST DAY OF SCHOOL Parent/Guardian Signature
Health Care Provider’s name _______________________________________________phone_________________ PLEASE LIST ALL MEDICATIONS THE CHILD TAKES (home and school) Name of Drug Dosage Times taken Purpose______________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Medication Allergies__________________________________________________________________ Other Allergies_______________________________________________________________________ Existing Medical Conditions_____________________________________________________________ (Example: diabetes, seizure disorder, depression, chronic conditions) Please explain on back of form further details regarding this medical condition. PERSONS TO CALL IF THE STUDENT IS SICK OR INJURED: (Name) (Home) (Work) (pager or cell phone) Mother_______________________ ________________ ________________ ____________________ Father________________________ _________________ ________________ ____________________ Guardian______________________ _________________ ________________ ____________________
Lipscomb Academy Health Services, 3901 Granny White Pike, Nashville, TN 37204.
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