Current Medications. Dose How often do you take it? Why do you take these and who prescribes them?
Current Medications. (Please list ALL prescribed, over-the-counter, routine & temporary medications, such as antibiotics. Include the dose and how often you take this medication) Medication: ___________________________________________________ Dose: _________________________ Schedule: ____________________________ Medication: ___________________________________________________ Dose: _________________________ Schedule: ____________________________ Medication: ___________________________________________________ Dose: _________________________ Schedule: ____________________________ Medication: ___________________________________________________ Dose: _________________________ Schedule: ____________________________ Past Medical History (surgeries, hospitalizations, injuries, etc…): ____________________________________________________________________ ___________________________________________________________________________________________________________________________________________ Allergies (check all that apply): Do you have allergies to any ◯ medications ◯ foods ◯ materials ◯ no known allergies Please list all allergies and reactions below. Leave blank if you have no known allergies. Allergen: __________________________________________________________________ Reaction: _________________________________________________ Allergen: __________________________________________________________________ Reaction: _________________________________________________ Allergen: __________________________________________________________________ Reaction: _________________________________________________ Dietary Information Do you follow a specific diet due to allergies, medical reasons or personal/religious beliefs? ◯ Yes ◯ No If yes, check all that apply: ◯ Gluten Free ◯ Vegetarian ◯ Vegan ◯ Dairy Free ◯ Other _________________________________ I agree that licensed health care statf and/or MASC/MAHS/MASSP statf members may administer the following medications (name brand or generic) as needed: ◯ Tylenol ◯ Motrin ◯ Advil ◯ Benadryl ◯ Antacid/Tums ◯ NONE Are there any over-the-counter medications that should NOT be administered? ◯ No ◯ Yes: ______________________________________ ⬚ By checking this box and signing below, I, the parent/ legal guardian of ____________________________________________________________ authorize MASC/MAHS/MASSP in conjunction with the student’s registered adviser/chaperone, to obtain emergency medical care for my child in the event such care is necessary. I understa...
