MEDICAL HISTORY NEW STUDENTS

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1 N A. Medical History ( 3 pages) to be completed and signed by parent or guardian. Signature required for enrollment. B. Physical Examination and Immunization Record ( back page) to be completed in full and signed by a physician and provide certificate of immunization. MEDICAL HISTORY NEW STUDENTS P A R T A Student s N ame Social Security # Home Address of Birth Parent/Guardian to be contacted in an emergency Relationship Address Home Business Telephone Home ( ) Cell ( ) Business ( ) Fax ( ) Family Physician Address Telephone ( ) Fax( ) INFLUENZA INOCULATIONS Asheville School medical staff gives flu shots each fall. I give my permission for this inoculation for my child. Initial one: Y es N o MEDICAL TREATMENT I certify that I am the parent or have the legal ability to sign this authorization on behalf of the student named above. In the event of illness or accident, I hereby authorize Asheville School, Inc. to act for me and in my behalf as the parent or other person having the legal authority to act for the student named above in the securing of medical treatment. In the event of an emergency, I hereby give permission to the physician selected by Asheville School, Inc. to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for the student named above. This authorization is in effect while the student is enrolled at Asheville School. Signature of Parent or Guardian (Required for enrollment) PROOF OF INSURANCE REQUIRED FOR ENROLLMENT AND PROVIDE FRONT AND BACK COPY OF INSURANCE CARD ame of insurance company Policy # Coverage code PLEASE RETURN COMPLETED MEDICAL FORM FOR NURSE TO REVIEW BY JUNE 1.

2 PART A PAGE 2 HISTORY OF INFECTIOUS DISEASE Please give age at which student was infected. Scarlet/Rheumatic Fever Tuberculosis Chicken Pox Mononucleosis Malaria Other HEALTH HISTORY Has the student had any of the following? If so, please check and explain below. Chest x-ray Allergies Serious injury or fractures Signficiant food allergies Loss of consciousness Reactions to injections Surgery Back or knee problems Passed out during or after exercise Psychiatric or psychological Dizzy during or after exercise problems or treatment Chest pain during or after exercise Other Please check and explain below. If more space is needed, attach an additional sheet. Frequent colds Heart condition Ulcer Sore throats Seizures Urinary problems Sinusitis Diabetes Arthritis Ear problems Family history Skin diseases Asthma of diabetes Acne Hay fever Depression Jaundice Bronchitis Anxiety Blood disorders Menstral problems ADD/ADHD Other Testicular problems Stomach upsets Are there any specific activities to be encouraged or restricted? Please give details. Any suggestions that would facilitate this student s medical care or adjustment to school would be welcome.

3 PART A PAGE 3 EYES ( Required) Student s eyes have been examined with the following results: V N N ision ear Distant Corrected to: ear Distant Right: Right: Left: Left: If glasses are required, please include a copy of the prescription. ORTHODONTICS Has there been any extensive dental correction or orthodontics? If so, please give details. Type of orthodonture If student is continuing orthodonture, please give name of orthodontist Orthodontist Address Telephone ( ) W ill the student require orthodontic care while at Asheville School? Y es N o If yes, please give name of orthodontist in Asheville if known of next appointment in Asheville of last visit to orthodontist W ill the student require dental care while at school? Y es N o If yes, what type? MEDICINES ALL MEDICATIONS MUST BE CHECKED BY THE SCHOOL NURSE ON REGISTRATION DAY A. Are there any allergies to medicines? B. Please give details of any medication the student requires.

4 PART A PAGE 4 Asheville School PHYSICAL EXAMINATION PART B To be filled out by a physician and to represent results of an examination made on this date: ( of examination) Code: 3 - Satisfactory X - Unsatisfactory (Please explain) Name of Birth Height Weight Blood Pressure Pulse LAB (Required) Hgb. Hct. Urinalysis Results Respiration Lungs Ears Heart Hearing Abdomen Nose Hernia Teeth Uper Ext. Thyroid Lower Ext. Tonsils Joints Skin Breasts Lymph Nodes Genitals Thorax Other IMMUNIZATIONS (Provide certification of immunization.) VACCINE *(5) *(1) *(4) *(2) *(3) *(1) *(1) DTP, DTaP, DT, or Td Tdap Polio OPV/IPV MMR Hepatitis B Varicella Meningococcal Hepatitis A Other one time dose after 11 years of age and 5 years since last Td or documented history of disease one dose required after 11 years of age Not Required (1) TB test MANTOUX Results: *Notes: Number of required doses per N.C. law for school registration Required within 1 year of Admission Explanations (If additional space is needed, please attach a letter or use space on Part A Page 2): Medications now being taken: Is this student restricted as to the kind or amount of activity or exercise he/she may take? q Yes q No If so, for how long? Why? Is he/she under any form of medical treatment? q Yes q No If so, for what condition? Is he/she allergic to any medication? q Yes q No If so, which type? Signed, M.D. Address Phone ( )

5 AUTHORIZATION OF MEDICATION FORM PART A: To be completed by medical provider: Student s N ame of Birth In order to keep this student in optimum health and to help maintain maximum school performance, it is necessary that medication be given. Medication Dosage Route Time(s) medication is to be given: Student may may not self-medicate. Special instructions and/or side effect( s) : If medication is ordered as needed, please indicate specific circumstances when medication should be given ( licensed nursing personnel will be administering medications). Signature of Medical Provider ( ) Telephone PART B: To be completed by parent or guardian. I hereby give permission for my child to receive medication during enrollment at Asheville School. This medication has been prescribed by a licensed physician. I hereby release Asheville School and its agents and employees from any and all liability that may result from my child taking the medication. Signature of Parent or Guardian ( ) Telephone

6 3 6 0 Asheville School Road Asheville, N C * * * MUST BE COMPLETED BY PHY SICIAN S OFFICE AN D SIGN ED BY PAREN T OR GUARDIAN IF APPLICABLE.* * * TUBERCULN PURIFIED PROTEIN DERIVATIVE TEST (PPD MANTOUX) ( must be done the beginning of this academic year) REQUIRED EVEN IF STUDENT HAD BCG N ame: given: Manufacturer: Lot # : Dose/Route/Site: Given by: Read by: read: Result (i n mm): If Positive (greater than 10mm) Chest x-ray required of chest x-ray: Results: Attach chest x-ray report * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * IF PPD WAS POSITIVE (greater than 10mm) and chest x-ray was negative, was INH (Isoniazid) treatment initiated? If so, give dates. From: To: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * If IN H treatment was refused, or not initiated, please sign below releasing Asheville School from any liability. Parent/Guardian Signature

7 Note: Please complete & sign this form. PSA Pharmacy is the contract pharmacy for Asheville School. This form will be sent to the pharmacy only if your child has prescription needs. PSA Pharmacy 2294 US Highway 70 Swannanoa, NC Phone Fax PSA Pharmacy is a locally owned, independent pharmacy specializing in servicing the pharmaceutical needs of patients in long-term care and other health care facilities, boarding schools, and at home. Our pharmacists have over 150 years of combined experience providing care to residents of Western North Carolina. PSA Pharmacy provides facility residents with all of their medication needs and works with facility personnel to ensure medication safety. Our services include: Delivery Service Medication Therapy Management Services by specially trained pharmacists. Specialized medication packaging to ensure safety and accuracy Prescription and non-prescription medications at competitive prices, including generically equivalent drugs Consultant Pharmacist-reviewed medication profiles Nursing and Med-tech in-services, including topics such as proper medication storage, med-pass, and new-drug updates. Computerized clinical records for your medical and nursing team Monthly billing statements Delivery of medications one or more times daily, and immediately for urgent needs. PSA Pharmacy has been providing care to patients in the Asheville-Buncombe County area for the past 35 years and enjoys an excellent relationship with Community Care Partners and Mission Hospital. We have had the pleasure of being the Mountain Area Hospice s pharmaceutical care provider since 1997 and have been providing pharmaceutical services to health care facilities since Pharmacists: Mike Tolley, RPh- Site Manager William F. Horton, RPh. Staff Pharmacist Pharmaceutical Care Specialist Teresa Pearman, RPh Staff Pharmacist Retail Pharmacy Specialist Everett Dunn, RPh Consultant Pharmacist Long Term Care and Geriatric Specialist Pharmacy Techs: Kelly Hamlin Opus Specialist/Billing

8 Kelly's ADDRESS:

9

10 CONCUSSION INFORMATION FOR STUDENT-ATHLETES & PARENTS/LEGAL CUSTODIANS What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the head. It results in your brain not working as it should. It may or may not cause you to black out or pass out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and your brain to move quickly back and forth. How do I know if I have a concussion? There are many signs and symptoms that you may have following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Here is what to look for: Thinking/Remembering Physical Emotional/Mood Sleep Difficulty thinking clearly Taking longer to figure things out Difficulty concentrating Difficulty remembering new information Headache Fuzzy or blurry vision Feeling sick to your stomach/queasy Vomiting/throwing up Dizziness Balance problems Sensitivity to noise or light Irritability-things bother you more easily Sadness Being more moody Feeling nervous or worried Crying more Sleeping more than usual Sleeping less than usual Trouble falling asleep Feeling tired Table is adapted from the Centers for Disease Control and Prevention ( What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed above, you should tell your parents, coach, athletic trainer or school nurse so they can get you the help you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer. When should I be particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your words are coming out funny/slurred, you should let an adult like your parent or coach or teacher know right away, so they can get you the help you need before things get any worse. What are some of the problems that may affect me after a concussion? You may have trouble in some of your classes at school or even with activities at home. If you continue to play or return to play too early with a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur Once you have a concussion, you are more likely to have another concussion. How do I know when it s ok to return to physical activity and my sport after a concussion? After telling your coach, your parents, and any medical personnel around that you think you have a concussion, you will probably be seen by a doctor trained in helping people with concussions. Your school and your parents can help you decide who is best to treat you and help to make the decision on when you should return to activity/play or practice. Your school will have a policy in place for how to treat concussions. You should not return to play or practice on the same day as your suspected concussion. You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not recovered from the injury. This information is provided to you by the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North Carolina Athletic Trainers Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North Carolina High School Athletic Association.

11 Student-Athlete & Parent/Legal Custodian Concussion Statement *If there is anything on this sheet that you do not understand, please ask an adult to explain or read it to you. Student-Athlete Name: This form must be completed for each student-athlete, even if there are multiple student-athletes in each household. Parent/Legal Custodian Name(s): We have read the Student-Athlete & Parent/Legal Custodian Concussion Information Sheet. If true, please check box. Student-Athlete Initials After reading the information sheet, I am aware of the following information: A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available. A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and classroom performance. A concussion cannot be seen. Some symptoms might be present right away. Other symptoms can show up hours or days after an injury. I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses. If I think a teammate has a concussion, I should tell my coach(es), parents, or medical professional about the concussion. I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms. I will/my child will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion. Based on the latest data, most concussions take days or weeks to get better. A concussion may not go away right away. I realize that resolution from this injury is a process and may require more than one medical evaluation. I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the injury. After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before concussion symptoms go away. Sometimes, repeat concussions can cause serious and long-lasting problems. I have read the concussion symptoms on the Concussion Information Sheet. Parent/Legal Custodian Initials N/A N/A N/A Signature of Student-Athlete Signature of Parent/Legal Custodian

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