Cardiac Medical Management Plan

Student Information

School Year: __________________

Student Name:

Date of Birth:

Physician’s Name:

Phone #:

Address:

Fax #:

Medical Details

List Known Allergies:

Brief Description of Condition:

Current Medications:

Name	Dosage/Route	School	Home

Special Equipment:

Symptoms Child May Demonstrate:

• Tires easily
• Shortness of breath
• Pain
• Other:

Vital Sign Parameters:

• B/P
• Pulse
• Respirations

Limitations:

Cleared without limitations including all physical activities and recess.

Not Cleared for (please be specific):

Emergency Procedures

If the student complains of chest pain, shortness of breath, and/or has vital signs outside acceptable parameters, school personnel should immediately:

• Call 9-1-1
• Contact Parent/Guardian
• Other:

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

Physician’s Signature:

Date:

Continued Cardiac Plan

For (Student Name):

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:

Authorization for Health Care Provider and School Nurse

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:

Print Name:

Date:

Parent/Guardian Contact Information:

Cell:

Work:

Parent/Guardian Contact Information:

Cell:

Work: