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 Name Student's Last Name
Student's Email *
example@example.com
Date

Month Day Year
mm-dd-yyyy
Is the student allergic to any medications?

YES NO
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?

YES NO
Does the student use an epi-pen?

YES NO
Is the student currently under a doctor’s care?

YES NO
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)

YES NO
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.) Soy Berries Peanuts Chocolate Yeast Eggs Garlic Chili Tomatoes Sesame Seeds Corn Oranges/Juice Pork Pistachios Pine Nuts Apples Grapefruit/ Juice Fish Tree nuts (Almonds, Walnuts, etc.) Shellfish (shrimp, lobster, crab, etc.) Wheat/gluten/Oats Pineapple Beans/Legumes Onions Kiwi Sunflower Seeds Spinach Chicken Beef Rice Potatoes Coconut
**Students are ultimately responsible for monitoring their own diet.
Signature of Parent/Guardian *

Clear
Date Signed

Month Day Year
Date