Medical Management Plan for Bleeding Disorders

Student Information

School Year: __________________

Student Name: __________________

Date of Birth: __________________

Physician’s Name: __________________

Phone #: __________________

Address: __________________

Fax #: __________________

Medical Information

List Known Allergies:

__________________

Brief Description of Bleeding Disorder:

__________________

Medications

Note: IV medications are not given by school personnel.

Medications:

__________________

Restrictions

List Restrictions: (including physical education activities; a doctor’s signature is required)

__________________

First Aid Treatment for Bleeding

• Apply ice to the site
• Call 911
• Contact Parent/Guardian

Other: __________________

Nursing Services Recommendation

Nursing services are recommended for the care of this student during the school day.

Physician’s Signature

Physician’s Signature: __________________

Date: __________________

Parent/Guardian Authorization

Authorization for Health Care Provider and School Nurse to Share Information:

I authorize my child’s school nurse to assess my child as it relates to his/her special health care needs and to discuss these needs with my child’s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.

As the parent or guardian of the student named above, I request that the principal or principal’s designee assist in the administration of medication/treatment prescribed for my child. I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.

Parent/Guardian Signature

Parent/Guardian Signature: __________________

Print Name: __________________

Date: __________________

Compliance and Independence

Is your child compliant with their current treatment regime? Yes / No

Does your child function independently with medication administration? Yes / No

Are there any activity restrictions for your child? Yes / No

If yes, please list: __________________

Contact Information

Parent/Guardian: __________________

Cell: __________________

Work: __________________

Parent/Guardian: __________________

Cell: __________________

Work: __________________