Medical Management Plan for Cystic Fibrosis

Student Information

School Year: _______________

Student Name:

Date of Birth:

Physician’s Name:

Phone #:

Address:

Fax #:

Allergies and Symptoms

List Known Allergies:

• Persistent coughing, at times with mucus
• Fatigue
• Wheezing or shortness of breath
• Upset stomach
• Recurrent respiratory infections

Medications

Medications taken at home:

Medications needed at school: Yes / No

If yes, please list:

Enzymes needed at school: Yes / No

Enzyme brand name:

# to be taken with snack:

# to be taken with meals:

Self Administration of Enzymes

It is my professional opinion that [Student name] should / should NOT carry and use enzymes by him/herself.

Special Considerations

Special equipment needed at school? Yes / No

Dietary modifications: (please list)

Activity restrictions: (excuse from physical education requires a physician’s note)

Fluids needed with physical activity? Yes / No

What type is needed?

Other modifications needed: (i.e. frequent bathroom breaks):

Nursing Services

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

Physician’s Signature:

Date:

Continued Cystic Fibrosis Plan

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 Information

Parent/Guardian Signature:

Print Name:

Date:

Parent/Guardian Cell:

Work:

Parent/Guardian Cell:

Work: