Education Service Center Region 12-Waco-UB-Student Medical Information File

Education Service Center Region 12
Upward Bound
MEDICAL INFORMATION

Student's Name

Student's First NameStudent's Last Name

Student's Email

example@example.com

Date

mm-dd-yyyy

Is the student allergic to any medications?

Please list:

Describe any medical problems UB should be aware of, such as asthma, allergies, or other medical conditions:

Does the student use an inhaler?

Does the student use an epi-pen?

Is the student currently under a doctor’s care?

If yes, please explain:

Is the student currently taking any prescription medications or long term medications?

If needed, is UB authorized to administer any over the counter medications?(Headache medication, Pepto-Bismol, Benadryl)

Briefly describe any limitations on the student’s physical activity

Please mark any foods that your student is allergic to and or should avoid because of dietary restrictions

**Students are ultimately responsible for monitoring their own diet.

Signature of Parent/Guardian

Date Signed

Date