This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below. Recommendations (Attach additional sheet if necessary): (Please Check One) This child may participate fully in school activities including physical education. This child may participate in school activities including physical education with the following restriction/adaptation. (Specify reason and restriction) ANTICIPATORY GUIDELINES Discussed and/or handout given SCHOOL READINESS 60 minutes of exercise/day Establish routines ORAL HEALTH After-school care/activities Regular dentist visits Friends Brushing/Flossing Bullying Fluoride SAFETY Communicate with teachers MENTAL HEALTH Sexual safety Family time Pedestrian safety Anger management Safety helmets Discipline for teaching not punishment Swimming safety Limit TV, computer Fire escape plan NUTRITION AND PHYSICAL ACTIVITY Smoke/carbon monoxide detectors Healthy weight Guns Well-balanced diet, including breakfast Sun Fruits, vegetables, whole grains, dairy Appropriately restrained in all vehicles Additional comments or recommendations: Signed: Date: Physician/APRN/PA/EPSDT Provider Address: Telephone:
This child has a health condition that may require emergency action at school, e.g. seizures, allergies. Specify below. Recommendations (Attach additional sheet if necessary): (Please Check One) This child may participate fully in school activities including physical education. This child may participate in school activities including physical education with the following restriction/adaptation. (Specify reason and restriction) ANTICIPATORY GUIDELINES Discussed and/or handout given SCHOOL READINESS Establish routines After-school care/activities Friends Bullying Communicate with teachers MENTAL HEALTH Family time Anger management Discipline for teaching not punishment Limit TV, computer NUTRITION AND PHYSICAL ACTIVITY Healthy weight Well-balanced diet, including breakfast Fruits, vegetables, whole grains, dairy 60 minutes of exercise/day ORAL HEALTH Regular dentist visits Brushing/Flossing Fluoride SAFETY Sexual safety Pedestrian safety Safety helmets Swimming safety Fire escape plan Smoke/carbon monoxide detectors Guns Sun Appropriately restrained in all vehicles Additional comments or recommendations: Signed: Date: Physician/APRN/PA/EPSDT Provider Address: Telephone: