ࡱ> =?< Rbjbj *,__F $(4"\\\\\f"h"h"h"h"h"h"$$'"0"\\{"8\\f"f"&!r!LX>!R""0"F!,Q( 6Q(r!Q(r!""Aj"Q(X f: Student Individual Emergency Medical Plan (IEMP) Students Name: ______________________ Sex:______ Birthday_____________ Parents/Guardians Name___________________________________ Students primary diagnosis or presenting problem: Describe characteristics of disorder and provide physician note of diagnosis and treatment and care while student at school. Ex. Seizure-what does it look like, peanut allergy-what happens, diabetes, severe asthmatic-describe symptoms. 1) 2) 3) Allergies: Yes_____ No____ If yes, what is he/she allergic to and describe their reaction. Medical History: Onset of disorder/illness & last episode: Current Medications: List any unusual behavior with medicines.  Medications Health Problem How often How given Physician  1. 2. 3. 4. 5. Students primary care physician (not specialist): Name:_______________________________________________Phone:__________________________ Address:_________________________________________________ May the school contact the physician in case there are questions or concerns in making an emergency care plan for your child? Yes________ No_________ Emergency Plan Please list below step by step plan of treatment for each health problem. Describe symptoms or behaviors. Usually these come from your physician and from your experience with your child. Please list symptoms when 911 is to be called based on your childs diagnosis or disorder.  Health Problem / disorder / symptoms Directions for care 1. #1 2. 3. 4. #2 1. 2. 3. 4. 5. Is your child prone to getting any particular health problem on a regular basis? Yes__ __ No___ Explain Is there a special way your child behaves when he or she is about to become ill? Yes____No___ Explain Please list specialists, clinics, therapists, or other physicians consulted for your child, the problems involved, and the dates of the most recent exam.  Doctor or Specialist Problem Date of last visit  1. 2. 3. 4. 5. May the school nurse contact any of the above listed health professionals in the event of a concern or a question: Yes___ No ___ Comments or explanations of answers to any of the questions on this form: The following procedures, ie gastric tube feeding, suctioning, use of VNS, etc are needed by my child at school following instructions from parents & or physician. Some procedures may be performed by classroom staff. List all procedures. Parents will provide all necessary equipment. Examples below as applicable: Seizure and Respiratory management. Administration of Oxygen, and monitoring with pulse oximeter, G-tube feeds and medicine administration, SVN treatments, Chest percussion, etc. ____________________________________________________________________________________ Parents please sign below and have physician sign. ___________________________________ __________________ Parents / Guardians Signature Date ____________________________________ __________________ Physicians Signature Date Physician may fax info to nurse at Attention: Nurse, FAX 623-80 Phone is 623-10. Student:________________________________ Birthdate__________ Teacher__________ Discussed IEMP, as outlined by parent/guardian, with students teacher. 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