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

MonthDayYear
mm-dd-yyyy
Is the student allergic to any medications?

YESNO
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?

YESNO
Does the student use an epi-pen?

YESNO
Is the student currently under a doctor’s care?

YESNO
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)

YESNO
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

Dairy (milk, ice-cream, cheese, etc.)SoyBerriesPeanutsChocolateYeastEggsGarlicChiliTomatoesSesame SeedsCornOranges/JuicePorkPistachiosPine NutsApplesGrapefruit/ JuiceFish Tree nuts (Almonds, Walnuts, etc.)Shellfish (shrimp, lobster, crab, etc.)Wheat/gluten/OatsPineappleBeans/LegumesOnionsKiwiSunflower SeedsSpinachChickenBeefRicePotatoesCoconutOther
**Students are ultimately responsible for monitoring their own diet.
Signature of Parent/Guardian*

Clear
Date Signed

MonthDayYear
Date