The Putney School Health Services
Health Forms – Instructions
All health forms for new and returning students must be submitted by July 15, 2015. The Putney School is obligated to request the submission of health forms every year for all students.
** Please note: health forms should not be submitted to Health Services. Please submit all health forms to our electronic medical record company below.
Please use the following checklist to ensure that all required forms are complete before your student arrives:
For parent/guardian/student:
Consent to Administer Medication form
Annual Philosophical and Religious Immunization Exemptions (required by the state of VT, if applicable)
Documentation of Varicella (Chickenpox) Disease (required by the state of VT, if applicable)
Concussion Policy Acknowledgement form – Student and Parent/Guardian
For health care provider:
Health History and Physical Examination form and immunization record (required)
Mental Health Report (if applicable)
Prescription Medication and Order Permission form (required if your child is on prescription medication)
Medical Immunization Exemption (required by the state of VT, if applicable)
Please mail health forms to:
CareFlow, LLC
Attn: Putney Forms
433 West Market St, Suite 6
West Chester, PA 19382
If you have questions for CareFlow
Technical support is available 7 days a week, 7AM to 7PM EST at:
Phone: 610-422-2969
For questions about health forms
Todd Pinsonneault, Dean of Students
Phone: 802-387-6242
The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
HEALTH HISTORY & PHYSICAL EXAMINATION FORM
To be completed by a licensed medical practitioner not related to the student.
The Putney School requires submission of this physical examination form on an ANNUAL basis.
Student Last Name, First Name:______Date of Birth (month/day/year):______
Health History - Check any of the following medical conditions the student has had or is being treated for currently:
ADD/ADHD / Chronic headaches / Hepatitis / Shortness of breathAllergies / Concussion / Hernia / Stomach pains
Anemia / Depression / High blood pressure / Seizures
Anxiety / Diabetes / Irregular heartbeat / Weight change (recent)
Asthma / Dizziness/fainting / Loss of eyesight / Weakness
Chest Pain / Eating problems / Menstrual cramps / Other
Chicken pox / Hearing loss / Mono
Chronic cough / Heart murmur / Rheumatic fever
List allergies to medications: ______
List other allergies: ______
List surgeries with dates: ______
List hospitalizations with dates:______
Other significant medical conditions: ______
If any interruption of scholastic career, please state conditions:______
______
To your knowledge, has this student experienced or been treated for an emotional, behavioral, and/or social difficulty in the past 2 years (e.g., parental divorce, relocation, substance abuse, or other unusually stressful situations)?
Yes ______No _____ If yes, please describe:______
______
Has the student had any emotional symptoms such as mood swings, depression, or unusual degree of anxiety or guilt? Yes_____ No_____ If yes, please describe:______
______
To your knowledge, has this student been in the care of a mental health professional(s) in the past two years?
Yes_____ No_____ If yes, a Mental Health Report must be completed by the mental health professional.
Immunizations: Please give date of each required immunization below, and attach information on other vaccinations.
DTap (diphtheria, tetanus, pertussis) vaccine – 5 doses
1st / 2nd / 3rd / 4th / 5thPolio vaccine – 4 doses / MMR (measles, mumps, and rubella) vaccine – 2 doses
1st / 2nd / 3rd / 4th / 1st / 2nd
Hepatitis B vaccine - 3 doses / Chickenpox (varicella) vaccine – 2 doses
1st / 2nd / 3rd / 1st / 2nd
Meningococcal vaccine – 1 dose REQUIRED for boarding students
If the student has previously had chickenpox disease, no vaccine is needed, and parents/guardians may sign the state of Vermont Varicella Documentation Form. For immunization exemptions, the physician must sign the state of Vermont Medical Immunization Exemption Form, and a parent/guardian must sign the Annual Philosophical and Religious Immunization Exemption Form.
(Please see reverse.)
The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
ANNUAL PHYSICAL EXAMINATION FORM
Student Last Name, First Name:______
Date of Birth (month/day/year):______Male:_____ Female:_____ Other: _____
Physical Exam: Height______Weight ______Blood Pressure______Pulse ______
Vision R______L______Corrective lenses?______Hearing Screen WNL_____ Abnormalities?______
Are there abnormalities, known injuries, or conditions of the following systems? Please explain in the space provided.
SYSTEM / WNL / ABNORMALITIESHead/ears/nose/throat
Eyes
Respiratory
Cardiovascular
Gastrointestinal
Hernia
Genitourinary
Musculoskeletal
Metabolic/endocrine
Neurological/neuropsychiatric
Skin
Any other condition?
Ankle
Knee
Shoulder
Other injury
Any restrictions?
Do you recommend referral to any specialty service? ______
Do you envision any need to make provisions and/or limitations in the student’s pursuit of a vigorous academic, extra-curricular, and/or sports/travel program? Yes____ No___ If yes, please describe: ______
______
To your knowledge, has this student been in the care of a mental health professional(s) in the past four years?
Yes _____ No______If yes, a Mental Health Report (included) must be completed by the mental health professional.
Does student regularly take medication of any type, including psychotropic medication or birth control pills?
Yes_____ No ______Please list all regularly scheduled medications and complete a Prescription Medication Order and Permission Form for each prescription medication the student will take while at school. It is important for Health Services to be aware of all medications students are taking in the event of an emergency at school. This includes day students who take medications at home.
______
______
IMPORTANT: You are asked to urge this student to have remedied, BEFORE ENTERING THE PUTNEY SCHOOL, any condition likely to cause interruption in success at The Putney School program. Please use a separate sheet to include further information or elaborate on any condition above.
Physician signature ______Date______
Physician name (please print) ______Phone______
The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
MENTAL HEALTH REPORT
This report is to be filled out by all mental health professionals that have provided services to the student within the past four years (copy form if necessary).
Student Last Name, First Name:______Date of Birth (month/day/year):______
To the Mental Health Professional: This student has already been accepted to The Putney School. In an effort to provide the most comprehensive services possible, it is important that we know of any emotional difficulties the student has had, should any mental health issues arise in our rigorous boarding school environment. Thank you for completing the following:
When and for how long did you see the student?
What were the presenting issues and the DSM V diagnosis?
What treatment was provided and how would you assess the outcome?
Was/is medication prescribed and if so, what?
List all hospitalizations:
Hospital / Dates / OutcomeSignature: ______Date: ______
Please print name: ______
License, Title, Degree: ______
The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
PRESCRIPTION MEDICATION & ORDER PERMISSION FORM
Prescription medication will not be given to students at school until Health Services receives this form completed and signed by the prescribing physician. The medication must be in its original container labeled by the pharmacy as prescribed by the physician. All regularly scheduled medications must be listed here and on the Permission to Treat Form so that, in the event of an emergency, the treating physician is aware of all medications. Please fill out instructions for each medication. The Putney School requires a new form to be submitted each time a medication changes.
Student Last Name, First Name:______
Date of Birth (month/day/year):______
Medication/Dosage / Frequency/Directions / Reason for takingPhysician name (print please): ______
Physician signature:______Today’s Date:______
Phone:______Email:______
The Putney School ■ Health Services ■ 418 Houghton Brook Road ■ Putney, VT 05346
CONSENT TO ADMINISTER MEDICATION
Student Last Name, First Name:______Date of Birth (month/day/year):______
MEDICATION POLICY AGREEMENT (ALL PARENTS/GUARDIANS)
I have read and understand the medication policy at The Putney School and agree to abide by its guidelines. I have reviewed the guidelines with my child. I understand that my child cannot possess any medication (over-the-counter, herbal, natural remedies, or prescription) without receiving permission from a school nurse. I am responsible for promptly updating Health Services with any changes in medications or as new medications are prescribed. I understand that that medicine will be disposed of if it is not picked up within one week following termination of the order or one week beyond the close of school. I understand that violation of this policy may result in a disciplinary hearing for my child. Parent/guardian initials Yes_____ No_____
PRESCRIPTION MEDICATION ADMINISTRATION CONSENT (ALL PARENTS/GUARDIANS)
I give permission for Health Services or school personnel designated by Health Services to administer prescription medications prescribed to my child. These medications may include prescriptions my child is currently on or medication prescribed while my child is at school. Prescription medications from home must be accompanied by a Prescription Medication Order and Permission Form signed by the prescribing caregiver. I understand that a new Prescription Medication Order and Permission Form is required for every change of medication, dosage, or other instruction. I understand that all prescription medication must be kept in its original pharmacy container with the appropriate label specifying student name, medication, dosage, route, and frequency or time of administration, and other special instructions. Parent/guardian initials Yes_____ No_____
OVER-THE-COUNTER MEDICATION ADMINISTRATION (ALL PARENTS/GUARDIANS)
I give permission for Health Services or school personnel designated by Health Services to administer over-the-counter medications to my child according to guidelines approved by the school physician.
Parent/guardian initials Yes_____ No_____
PARENT CONSENT FOR SELF-ADMINISTRATION OF MEDICATION (ALL PARENTS/GUARDIANS)
I give permission for my child to self-administer medication, provided that Health Services determines it is safe and appropriate. I feel comfortable that my child can responsibly administer him/herself medications. The Putney School can provide support and teaching to students taking medication, but does not assume responsibility for students who self-administer medications (prescription, over the counter, or natural/herbal remedies) as prescribed by a physician. The option for self-administration excludes all controlled substances, which must be stored according to school policy and administered by Health Services or school personnel designated by Health Services.
Parent/guardian initials Yes_____ No_____
______
Parent/guardian signature Date
STUDENT AGREEMENT FOR SELF-ADMINISTRATION OF MEDICATION (ALL STUDENTS)
1. I have read the medication policy and will abide by its guidelines.
2. I understand that I am responsible for taking medications as directed.
3. I will safely store the medications and keep it packaged as Health Services directs. I will report lost medication to Health Services immediately.
4. I agree to contact an adult on campus if I do not feel well, or if I have a question about my medication.
5. I agree to NEVER share my medication with anyone.
6. I agree to NOT keep medications in my dorm room or with me unless authorized to do so by Health Services.
7. I understand that not following these guidelines may result in a disciplinary process.
______
Student signature Date
The Putney School ■ Health Services ■ 418 Houghton Brook Rd. ■ Putney, VT 05346
Phone: 802-387-6221 ■ Fax: 802-387-6228 ■ Email:
Allergy Injection Policy
Allergy injections are administered at the Brattleboro office of the school physician or at The Putney School infirmary.
Adverse reactions to allergy injections, though rare, are well-documented in medical literature. These reactions can be life-threatening. Due to the possibility of potentially serious reactions, the student and parent/guardian will be offered the option to have allergy injections administered at the Brattleboro office of the school physician. There will be a transportation fee and physician co-pay, if required by the student’s insurance plan, for this service.
Because the risk of severe reaction is low and because many students have received injections at previous schools, we recognize that some students and parents/guardians may prefer to continue injections at school. This decision must be made with the understanding that there is NO physician on the premises. Health Services staff may administer allergy injections ONLY when there are two registered nurses present in the office. The student will be required to be observed for thirty minutes following the injection(s).
If, after reviewing this policy, considering the implications of having the injections administered at the school, and discussing this with the student’s allergist, I, the undersigned, am willing to assume the risks. This release form must be signed and returned, along with instructions and medications from the prescriber, to Health Services before any injections can be given.
______
Parent/Guardian Signature
______
Parent/Guardian Name
Date ______
The Putney School ■ Health Services ■ 418 Houghton Brook Rd. ■ Putney, VT 05346
Phone: 802-387-6221 ■ Fax: 802-387-6228 ■ Email:
ALLERGIST CONSENT FORM
The Putney School Health Services (Health Services) provides allergy injections as a service to students and reserves the right to discontinue administration of injections to students who fail to comply with their prescribed regime, or who fail to notify the health office of changes in their regime.
Allergy injections are only to be administered within the following guidelines:
Students must have instructions from their prescribing physician, clearly labeled with the student’s name and the physician’s name, address, and phone number. Instructions must include serum to be used, dosages, and injection intervals. The Putney School nursing staff will consult with the prescribing physician when necessary to clarify instructions.
Students must provide their own serum, which can be stored in The Putney School Health Services refrigerator.
Due to the increased risk of anaphylaxis, students who have not received allergy injections previously, or who are resuming injections after a four-month layoff, must receive the initial injection at the prescribing physician’s office.
There is no physician available when allergy injections are administered at The Putney School, however, there will be two registered nurses present during the time allergy injections are given and during the waiting period post-injection.
Individual receiving injections must remain in Health Services for a period of at least (30) thirty minutes after in the injection(s) is/are administered.