Christi Reger BSN, RN » Medical Forms

Medical Forms

Health Forms/ Action plans for CHM and RCS 
All health-related concerns should be addressed on the health form on skyward to be filled out at registration. If you have any additional health related concerns regarding your child, please contact the school nurse.
Nurse Christi Reger BSN, RN   [email protected]    615-904-3885 ext 29720 
 
ALL MEDICATIONS MUST BE SIGNED IN BY A PARENT / GUARDIAN! 
Over the counter medications must be in a new unopened container that is not expired.
ALL prescription medications must be in original pharmacy container with current prescription label with CURRENT COMPLETED Action Plan or Medication Authorization form (completed and signed by parent and doctor). ***see below.
 
Any and all completed forms may be turned in using the following:
Fax to: 615-904-3886 Attention School Nurse 
Turn in to: Nurse's Office in person 
Asthma
If your child has been diagnosed with Asthma. please have the Asthma Action Plan filled out as soon as possible. It does require a physician's signature.  If your child has an inhaler and/or spacer, they will have to be signed in by a parent/guardian at the beginning of the year even if they are able to self-carry. Please bring in original package with current pharmacy label. Physician must mark the self-carry section for student to be able to keep the inhaler with them. 
Allergy or Anaphylaxis
If your child has been diagnosed with an Allergy (Anaphylaxis - severe allergic reaction), please have the Allergy Action Plan filled out as soon as possible. It does require a physician's signature. All medications needed for the allergy it will have to be signed in by a parent/guardian.

**In accordance with Public Chapter 628 of 2020, the attached standardized form for students with an allergy, to be used to report the allergy to the school in which the students are enrolled, has been developed by the department of education, in consultation with the department of health. Each school district shall require each school in the district to use the form to maintain a record of any student who has reported having an allergy.

Cardiac 
Fill out the form below to inform the school of any Cardiac conditions your child may have.  Have your physician sign where applicable. If your child has medications, they will have to be signed in by a parent/guardian at the beginning of the year.
Diabetes
If your child has been diagnosed with Diabetes (Type I / II), please contact the school nurse to verify that the diabetic orders have been received. If your child is under the care of Vanderbilt or Centennial, they should provide orders for school use prior to school starting, (if patient at VUMC you may print current copy of order and individual health plan from your patient portal).  If your child is not under the care of Vanderbilt or Centennial, contact school nurse for Diabetic school orders.  These can be taken to your doctor to fill out before the first of the year.  Once completed, bring to the nurse's office with any medications and supplies needed to keep at school. All medications will have to be signed in by a parent/guardian at the beginning of the year.
Contact information for the doctor's office:
Christiana Middle School - Phone: 615-904-3885 ext. 29720 Fax: 615-904-3886 
Seizures
If your child has been diagnosed with a Seizure Disorder, please come to the Nurse's Office at the beginning of the school year to discuss doctor's orders and a Safety Plan. Below are a few forms you can have filled out before school starts. If your child has medications, they will have to be signed in by a parent/guardian at the beginning of the year.
Pulmonary Conditions 
Fill out the form below to inform the school of any Pulmonary conditions your child may have.  Have your physician sign where applicable. If your child has medications, they will have to be signed in by a parent/guardian at the beginning of the year.
Sickle Cell 
If your child has sickle cell below is the action plan. Please fill it out and have the physician fill out their section and return it to the school nurse at the beginning of the school year.