Health History: (check all that apply) Allergies: (check all that apply) Child must be able to be independent in their diabetes management. …
Medical Private Information Form
Students Name:_______________________________________________________
Date of Birth ____/____/____
Please Print Last
First
Middle
Health History: check all that
apply Aller
gies: check all that apply
____Asthma
____ Aspirin
____ Cardiac
Problems
____ Insect Stings/ Bites
____ Epilepsy or
Seizures
____ Penicillin
____
Diabetes
____ Sulfa
____ Orthopedic Problems
____ Tetracycline
____ Other _____________________ ____
Latex
_________________________________ ____ Food
_________________________________________
_________________________________ ____
Other _________________________________________
Any conditions now requiring regular medications? ____ Yes
____No
Conditions:
____________________________________________________________________________
______
|Name of Medicine |Dose |Times Given |Who administers? |
| | | | |
| | | | |
| | | | |
Has student had a tetanus shot within past six years? ____ Yes
____No
Morgantown Theatre Company MTC does
not have a nurse on duty and so is
not able to administer medications to your child
Is it possible that your child may need to self-administer a medication
during theatre practice? ____ Yes ____ No
If your child will need to self-administer a medication during theatre
practice, a note from your doctor on a Physician Order Form located on 2nd
page will be required
If your child has asthma and requires an inhaler during theatre
practice, you must bring a licensed prescribers order for the childs
self administration of the inhaler on a Physician Order Form located
on 2nd page Children may carry an inhaler with them if orders from
the physician state this
If your child has an insulin pump for the self-administration of
insulin, you must bring a licensed prescribers order for the
childs self-administration of the insulin on a Physician Order
Form located on 2nd page Child must be able to be independent
in their diabetes management
Does your child have any severe allergic reactions that might require them
to self-administer Benadryl or use an Epi-Pen?
Yes___ No___ If yes, please
describe
______________________________________________________________________
All children that may need to self-administer Benadryl or an Epi-pen
for their allergy must bring a licensed prescribers order for the
childs self administration of the medication on a Physician Order
Form located on 2nd page
Does your child have medical insurance? _____Yes ____ No
Policy
:________________________
_____
If yes, Name of Insurance
Company:_________________________________________________________
Physicians name:___________________________________________
Phone ______________________
Preferred Hospital: __________________________________________
Does your child have any limitations that would affect participation in
theatre/dance activities or assistance with changing sets or reading and
memorizing scripts? If yes, please
describe
_________________________________________________________
____________________________________________________________________________
___________________________
I have read and completed the above information I understand that MTC may
share the above information confidentially with emergency personnel if
needed
_______________________________________ ______________________
Parent/Guardian signature Date
_______________________________________
Parent/Guardian print name
If there is any personal or private information that you would like to
share confidentially with MTC, which you believe would make your childs
experience at MTC more enjoyable or otherwise better, please indicate
here:
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
———————–
Physician Order Form
Morgantown Theatre Company
369 High St
Morgantown, WV 26505
291-6826
Childs Name: _____________________________
Childs Condition/Diagnosis:
__________________________________________
Physician Order for childs self administration of medication
while at MTC for theatre practice or for emergency
self-administration
of Benadryl or Epi-pen in the case of severe allergies
[Note to physicians: children are usually at theatre practice
after school, some time between 3:30 and 9:00 pm, but close to
the dates of performances, practices may be on weekends or holidays
for long stretches of time between 10:00 am and 9:00 pm]
I understand that there are no licensed health care providers at Morgantown
Theatre Company
____________________________________ ______________________
Physician Signature Date
Source:admc.hct.ac.ae
