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John de la howe school assessment form

John de la Howe School
This form is required prior to admissions into either of the Joh n de la Howe School programs. Please have this form completed by your family physician and fax it to (864) 391- 2150. Completion of the physical is not a contract between the
applicant, medical facility, or families for placement. All c ost associated with the Physical Examination will be the
responsibility of the family submitting the applicatio n for placement. A copy of your child’s medical information will be
submitted to our medical staff for review and approval. If our medical department deems your child suitable and free of any
serious medical condition(s), and the child is accepted for pl acement our residential department will contact you with a placement date for your child to report.
Student’s Full Name: __________________________________________________ Date of Birth: ________________________________
Height: ________ Weight: _________ Blood Pressure: ______________ Temp: _______ Pulse: _______(RRR) Respiration: __________
Hearing (Whisper): (R): _____________ (L): ________________ Is an audiometric exam recommended? Y or N
Uncorrected Vision: (Snellen) (R): 20/ ___ (L): 20/ ___ Are corrective lenses worn? Y or N Date of last prescription __________
Corrected Vision: (Snellen) (R): 20/ ___ (L): 20/ _ Is a complete eye examination recommended? Y or N
Dentition (list and describe any problems): __________________________________________ Is a dental examination recommended? Y or N
Allergies (medication or food): Y or N (if yes, please list them and their reactions): ______________________________________________

Last Tetanus shot: ___________ Has the student had Chicken Pox? _________ If no, has he/she been immunized for this disease? ____________
Required Lab Work: (Tests must have been performed within the last 90 days)
URINALYSIS: Date: ______________ Specific gravity: ________ Albumin: _______ Sugar _________ Mic: ________ Bacteria: _________
TUBERCULIN SKIN TEST: Date: ____________________ Results: ______________________ Date read: ___________________________

Key: N=Normal X= Abnormal
_____ Head ______ Nose _______ Ears _______ Lungs _______ Heart _______ Arches
_____ Mouth ______ Throat _______ Abdomen _______ Upper Extremities _______ Spine _______Toenails
_____ Eyes ______ Neck _______ Liver _______ Lower Extremities _______ Feet

Last menses (female): ___________________ Regular? (Y?N) ___________ Last examination for hernia (Male): ___________________
NEUROLOGICAL: _____________________________________ ___________________________________________________
MEDICAL: ___________________________________________
___________________________________________________ PSYCHOLOGICAL/EMOTIONAL: ________________________ ___________________________________________________
I certify that I have personally examined this patient and find no abnormalities, except as indicated above, that would prevent he/she from
participating in physical training activities.

DATE: _________________________________ PRINT AND SIGN: ____________________________________________________________________, M.D.
ADDRESS: _______________________________________________________________________________ PHONE: ________________________________
(A Licensed Physician must complete this form)

John de la Howe School Student Medical History
NAME: ___________________________________ Date of Birth: _________________________ Today’s Date: _____________
Height: _______________ Weight: _________________ Social Security Number: ____________________________________
Please check any of the following that the student or his/her immediate family may have experienced. Key: (St=Student, F=Father, M=Mother, S=Sister, and B=Brother)
_____ Cancer _____ Swollen/Painful Joints _____ Hemoglobinopathies (i.e.; Sickle Cell and Tay-sachs) _____ Eyes/Vision _____ Chronic/frequent colds _____ Dental Problems _____ Recent weight gain or loss Do you ……
_____ Ears/Nose/Throat _____ Pain/Pressure in Chest _____ Diabetes _____ Palpitations/pounding heart _____ Epilepsy/Seizures _____ High Blood Pressure _____ Hearing Loss _____ Frequent indigestion _____ Dizziness or fainting _____ Stomach problems Use street drugs? (If so please list below _____ Headaches (Chronic) _____ Liver problems/jaundice Have you ever ….
_____ Headaches(Migraine) _____ Broken bones _____ Sinusitis _____ rupture/hernia Attempted suicide?
_____ Heart problems _____ Frequent/painful urination Had any illnesses or injuries other than _____ Intestinal problems _____ Sexually Transmitted Diseases the ones listed to the left? _____ Kidney problems _____ Bone/joint deformity bands? _____ stomach ulcers _____ Recurrent back pain For females only
_____ Thyroid problems _____ Shortness of breath Ever been treated for a female disorder? _____ Skin diseases _____ Depression/excessive worry Are you sexually active?
For each item checked above, please explain your answer in the space provided below ( may use back of sheet if necessary) .
Please list your current medications: __________________________________________________________________________________________
Have you even been on medication for ADD or ADHD? Y or N Was there any improvement? Y or N
What was(were) the name(s), dosage(s) and date(s) of the medication(s)? ____________________________________________________________
Why did you stop taking the medication(s)? ________________________________________________________________________
Have you ever been on medication(s)? Y or N Was there any improvement? Y or N
What was(were) the name(s), dosage(s) and date(s) of the medication(s)? ____________________________________________________________
Why did you stop taking the medication(s)? ______________________________________________________________________
What is the name of your Health Insurance Company? ____________________________________ Effective Date: __________
Whose name is the insurance listed under? _________________________________________________ Date of Birth: ____________

What is the Identification Number or Group Number of the Insurance Policy? ________________________________________
_______________________________________ ___________________________________________
Student’s Signature Parent/Guardian’s Signature
John de la Howe School
I, ____________________________________________________ hereby voluntarily consent to the rendering of such care, including
(Printed name of parent/guardian)

immunizations, diagnostic procedures, surgical and medical treatment and blood transfusions, by medical doctors, hospitals or their
authorized designees, as may in their professional judgment be necessary to provide for the medical, surgical or emergency care of my
dependent child, _____________________________________
(Printed name of dependent child)

I further give my consent to John de la Howe School to arrange for routine or emergency medical and/or dental care and treatment
necessary to preserve the health of my dependent child. In the event that my dependent child is injured or ill while under the care of
John de la Howe School, I hereby give permission to John de la Howe School to provide first aid for said child and to take the
appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the
nearest emergency medical facility.
I further give my consent to John de la Howe School to contact my dependent child’s routine medical/dental provider(s) as necessary
to discuss my dependent child’s medical history, medications, and routine and/or ongoing medical/dental needs.
In making medical decisions on my behalf for the benefit of my dependent child, I direct that John de la Howe School attempt to
contact me. However, if medical care becomes essential, I give permission to John de la Howe School to make such decisions
regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any
treatment decisions to be made by John de la Howe School on my behalf for the benefit of my dependent child, I authorize John de la
Howe School to request, obtain, review and inspect any and all information bearing upon my dependent child’s health and relevant to
any such decisions to be made respecting such treatment.
I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my
dependent child and that I am responsible for all reasonable charges in connection with the care and treatment rendered to my
dependent child during this period.
This authorization of consent becomes effective on the
and will remain
in effect until the child is discharged from John de la Howe School.

Dated this

Parent/Guardian Signature Section
John de la Howe School Signature Section
(Printed name of John de la Howe School Representative) (Signature of John de la Howe School Representative) John de la Howe School
Prescription Medication Authorization Form

Dear Parent or Guardian:

Nonprescription Medications:

Parent/Guardian written authorization is required.
Prescription Medications:

Parent/Guardian written authorization and Physician written authorization is required.
No medication will be administered by John de la Howe School personnel or its agents until the consent forms are
completed and on file with the school nurse.
Medication authorization and administration forms will be kept and stored confidentially.
All prescription medication must be in the original container labeled from the pharmacy with the student's name, dosage,
time, and quantity to be given.
All medication will be kept in a securely locked area only accessible to those who have the authority to administer
medications to the students.
Parents are responsible for bringing/sending medication to the school and picking up any unused medication after it has
been discontinued.
Students are not allowed to have medication on their person.
Personnel that administer medication to students will be provided orientation and training.
In accordance with the standards of nursing practice, if the school nurse determines a medication dosage has the
potential to be harmful or dangerous, based on her/his experience, assessment and professional judgment, he/she may
refuse to administer or allow administration of the medication. In these cases, the school nurse will notify the
parent/guardian and the licensed prescriber of the reason for the refusal.
Heather Sizemore, RN
John de la Howe School
John de la Howe School
Medication Authorization Form
(Note: Each medication requires a separate form)

Parent or Guardian to complete this section:

Student’s Name: ___________________________________

School: John de la Howe School
Medication: _______________________________________ Dose: _________________________________ Benefits of medication: _______________________________________________________________________ Route/Mode of Administration: ________________________ Frequency: _____________________________
Duration: ______________________________________________________________ (Not to exceed current school year)
Times to be given: ____________________________ Start Date: ____________ Stop Date: _____________
Potential Adverse Reactions: ___________________________________________________________________
If medication is ordered PRN (as needed), state conditions under which school personnel should administer medication
(i.e. headache, fever, pain, cough, etc.):
I hereby give permission for personnel designated by the principal or school nurse to give this medication to my child
according to the directions stated.
I also authorize designated personnel to contact me if there is a question regarding medication administration.
I agree to provide documentation from a doctor to the school when the drug is discontinued and/or the dosage or time
I understand if the medication is discontinued and then resumed, a new Medication Authorization Form is required.
I understand that any unused medication will be properly disposed of if not claimed after discontinuation of the medication.
Discontinued medication will be sent home only with the student’s parent or guardian.
I agree to hold John de la Howe School, its employees and agents harmless in any and all claims arising from the
administration of this medication.
X ________________________________________ Date: __________________________
(Parent or Guardian Signature)
Home Phone: _______________________________________ Work Phone: ____________________
John de la Howe School
Prescription Medication
Physician Authorization

(Please complete a separate authorization for each prescribed medication ordered)

I acknowledge that I will assist and advise designated personnel in the administration of the below prescribed medication.
I agree to provide the school nurse with documentation of the student’s follow-up visits and changes of
medications/dosages or frequencies.
I will provide copies of prescriptions written to the school nurse for placement in the student’s medical record (which will
be maintained in the Infirmary), since John de la Howe School is a residential placement.
Student's Name: _____________________________________ Date of Birth: ___________________________
Diagnosis: ________________________________________________________________________________________
Medication: __________________________________________
Benefits of medication: ______________________________________________________________________________ Route/Mode of Administration: _____________________________ Frequency: _____________________________ Duration: ___________________________________________________________________ (Not to exceed current school yr.) Times to be given: _______________________________ Start Date: ________________ Stop Date: ______________ Special Instructions for Administration: __________________________________________________________________ Potential Adverse Reactions: _________________________________________________________________________ _________________________________________________________________________________________________ If adverse reactions are noted please notify the student’s parent/guardian as soon as possible. Request that school nurse see the student for any of the following reasons: _____________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _____________________________________ _____________________________________________ ________________________________________ __________________________________________________ __________________________________________________________________________________________________________ Physician’s Office Address John de la Howe School
Over-The-Counter Medications
(Circle Medications Approved and/or Check Al Medications Approved to be Provided to Student)
Advil (headaches, menstrual cramps, fever) Orajel (toothache, sore gum, mouth sore) Antifungal Spray (athlete’s foot, jock itch) Pepto-Bismol (nausea, diarrhea, upset stomach) Swimmer’s Ear Drops (earache from swimming) Triple Antibiotic Ointment (cuts, scrapes) Epsom Salt (sore joints, ingrown toenails) Check here if al medications are approved for use as needed: _______ Parent/Guardian’s Initials: ___________________ Date: ___________________ Student’s Name: __________________________ Cottage: __________________


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